MedStar Health DocTalk
Comprehensive, relevant and insightful conversations about health and medicine happen here… on MedStar Health Doc Talk. Join us for real conversations with physician experts from around the largest healthcare system in the Maryland-DC region.
MedStar Health DocTalk
Hand Tumors: Lumps and Bumps
Bumps and lumps of the hand can be any number of things... all are classified as a hand tumor, but do they all require treatment, and which are a cause for concern? Host Debra Schindler explores the various types of hand tumors from the benign to malignant, with hand surgeon and Chief of the Curtis National Hand Center, Dr. James Higgins, and orthopedic oncologist, Dr. Mohammed Karim. Learn about the variety of hand tumors, treatment options, and the importance of early diagnosis. Don’t let uncertainty hold you back— peace of mind is everything.
If you have concerns about a hand tumor and would like to see a specialist call 877-34-ORTHO or 877-346-7846. If you’re from outside the Maryland area, ask for a video consult appointment.
If you would like to provide feedback on this podcast, or get more information on hand tumors, send Debra an email: debra.schindler@medstar.net.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
Comprehensive, relevant and insightful conversations about health and medicine happen here on MedStar Health DocTalk These are real conversations with physician experts from around the largest healthcare system in the Maryland D.C. region. Take a look at your hand for just a minute. It contains 27 bones, 14 that make up the fingers, muscles, tendons and ligaments. Three major nerves control sensation and movement, and finally, a network of arteries and blood vessels circulate blood all the way to our fingertips. So when, a lump develops in the hand or wrist where, you know, there isnt supposed to be one, how does that impact the complex and intricate structure of the limb we are most dependent on? Today on MedStar Health DocTalk I am joined by two experts in the field of hand surgery and an orthopedic oncology to better understand what hand tumors are and how they are treated. Welcome Dr. James Higgins Chief of the Curtis National Hand center here at MedStar Union Memorial Hospital in Baltimore. It'the largest hand center in the world and known internationally for advancing the science, research and education of surgery of the hand and upper extremity. Also Joining us is MedStar Health orthopedic oncologist Dr. Mohammed Karim, who is uniquely dual fellowship trained in spine surgery and orthopedic oncology, and specializes in the treatment of bone and soft tissue tumors. Thanks for being here, Dr. Higgins and Dr. Karim
>> Dr. James Higgins:Thanks for having us, Deb. We're excited to be here.
>> Dr. Mohammed Karim:Absolutely. Thank you for having us.
>> Debra Schindler:So the word tumor can sound very alarming. The good news is that most hand tumors are benign. But do we call lumps and bumps in the hands tumors if they're not cancerous, what is a hand tumor?
>> Dr. Mohammed Karim:That's a great question, Deb. indeed. Any growth anywhere in the body is technically a tumor. So a little wart on your fingers, technically a tumor. But not all tumors are cancerous. The vast majority are, in fact, not cancerous. What makes tumor cancerous is its ability to shoot out little seeds that spread to different parts of the body. So those are what we call malignant tumors. Benign tumors can grow. They can be painful, annoying, disfiguring, but they won't spread all over your body and do bad things like compromise your life. And that's reassuring. Cause the vast majority are in fact, benign. But there are some that are malignant as well. And malignant tumors are what we call cancer.
>> Debra Schindler:So in the research that I did in preparing for today, I saw that the most common lumps in the hand have been referred to as a Bible bump. Dr. Higgins do you want to tell us what that is?
>> Dr. James Higgins:Yeah. So this is an often asked question, and this is a term that, dates way back to a time period where people were trying to treat ganglion cysts of the wrist, primarily without surgery or without needle aspiration. So as it turns out, there is a benign cyst that can develop on the back or front of your wrist. And these are, often painless, but sometimes can be painful. When people see them, they can be alarming, and they will present to our offices and ask, what can be done about them. It's true, they can sometimes rupture, meaning literally, the balloon full of fluid that's underneath your skin can rupture, and the fluid can disperse painlessly underneath your skin, and that makes the bump go away. So there was a day where it was recommended by primary doctors to simply impact the bump with some heavy object at home. And oftentimes the heaviest object was a Bible. So these were ultimately named Bible Bumss, sort of as a, ah, street name for them. But we try not to recommend that anymore. and it is true that they can sometimes disperse like that, but we will typically either watch them over time and reassure patients that they're not dangerous, or we can stick needles in them to drain them and take the fluid out so that the bump ostensibly disappears. And sometimes we even surgically remove them.
>> Debra Schindler:Well, what is a ganglion cyst? I mean, how does it start? Is it preventable, and will it stop growing if you just leave it alone?
>> Dr. James Higgins:So they are collections of fluid that come out of joints, usually, and the joint has a flange around it that holds in the joint fluid. That flange is material that has a consistency of sort of jellyfish. So it's very mobile, slick substance that can actually herniate out. When we use word herniate, meaning it creates an out poouching that fills with the joint fluid, and if that sits underneath your skin, it gives the appearance of a large bump. But that's what a ganglion cyst is. That's completely benign. It's not anything to be concerned about. And it's often spontaneous, meaning there's nothing you can do to prevent it, there's nothing you do to predict it. And, it's not the result of an injury. So they'certainly one of the most reassuring diagnoses that we come across. We can always tell patients with great certainty that it's nothing to be concerned about.
>> Debra Schindler:When you see them in your office, do you treat them or no. Do you recommend? No.
>> Dr. James Higgins:Well, typically we'll treat them if they hurt, if they're causing symptoms for patients, and more often than not, patients will elect to have a needle to drain them because it's so simple to do. We do it in the office. It's relatively painless. But really the more important thing is when people come to our office and they think they have a gangl, they cy. That means they have a bump of some sort. And as Dr. Cream said, there are numerous tumors. Some are benign, some are not. And it's worthwhile having those checked out so that we can reassure you that indeed it is a ganglion cyst or some other benign tumor.
>> Debra Schindler:Okay. The other common tumor or nodule and the hand is a dupitran nodule. And I just diagnosed my husband with this, I really did. He has it on the open palm now. It hasn't pulled in his fingers, which is a common trait of dubitrans. Yes, and I'll let you talk more about that. But it is definitely protruding from the skin. It's just a little pea sized lump on the inside of his hand. Would you say that that is what it is?
>> Dr. James Higgins:Yes. And these are us usually, I think your diagnosis correct, although it would be best if I checked them out.
>> Dr. Mohammed Karim:Right.
>> Debra Schindler:I'm going to bring them in.
>> Dr. James Higgins:I will bring them in really firm and as we'll chat. All of these bumps have different characteristics. And, a lot of what we do is just try to guesstimate based on how hard or soft, it is. Is there some discoloration? Are there skin changes? We literally use some very basic techniques, like literally shining light on some of these structures to try to determin if they have the characteristics of certain diagnoses. So a Dupatran's lump is almost certainly on the Palmer side of the hand. There are rare ones that occur in the back of the hand, but they're almost always on the palm side of the hand. They most commonly occur along the axis or the pathway of the ring finger. And they are firm. They're quite firm and painless. So it push as hard as you might want. It typically is not tender nor does it cause pain. So these are the sort of typical characteristics of it. And it's true that it's more commonly seen in men than women. And we do see this way more commonly in patients of Northern European descent. So there are a bunch of clues, that will lead you to a diagnosis without necessarily having even taken X ray or an MRI or take a piece of tissue. Dupatns is a relatively easy one. For us. And I'm sure Dr. Cream sees it all the time as well. But it has very distinctive characteristic. So you can tell the moment you see patient's hand. You're probably correct about your husband.
>> Debra Schindler:How long before, he can expect his fingers to start pulling in towards his hands?
>> Dr. James Higgins:maybe never. Yes, never. So when that happens, although it sounds dramatic, it's painless and it's slow. It sort of glacial in its pace. So if his fingers were to be drawn in, as people say, making it unable for him to straighten them, that would generally occur over years. It's at that point that they typically show up in our office and say, hey, I can't straighten my fingers anymore.
>> Debra Schindler:And I can't play the guitar. I can't put my hand in my pocket. I can't use my hand very well.
>> Dr. James Higgins:Yeah, yeah. Usually the most common complaint, I can't get my hand in a glove because the fingers come down so much that it's very difficult to sort of slide a glove on. So we hear comments like that all the time. that's another super reassuring diagnosis, Meaning not at all dangerous and not requiring any necessarily any treatment or certainly nothing urgent.
>> Debra Schindler:Good. So what other kind of tumors are there? I show a list of five, six. Six other tumors. Do you want to talk about those?
>> Dr. Mohammed Karim:There are so many, and they have so many different names and long, complicated ones. But, you know, I think the important point here is that our hand surgeons, like Dr. Higgins, routinely see some of these common ones, like ganglion cysts and Dupuytrens contractors or nodules. So it always sticks out to me, as an orthopedic oncologist, is when a hand surgical colleague calls me and says, this doesn't seem right, because in fairness, they see a ton of lumps and bumps in the hand all day long, and they know what's normal and they know what's one standard deviation away from normal. I take it very seriously when a hand surgical colleague calls me and says, something about this one seems different. And then we start to say, okay, something about this seems different. The location is different than usual. The feeling is different than usual. It's painful. And then we have to start opening up our list of what else it could be besides the common ones. Tumors, can occur along any of the structures that you had mentioned in the hand. For instance, you can have tumors that occur along the nerves, and those are notoriously painful. There are benign ones. There are malignant ones. They have long names like neurofibroma or neururalomoma. Schwannoma glomus tumors. All of these things arise from the nerve elements that break up our hand. And they can be painful and they're all benign. There are some malignant ones as well. There's a malignant peripheral nerve sheets tumor mpnst but the bottom line is that there are other kinds of tumors that present in a way that's seem atypical to my colleagues who see lumps and bumps all day long. And that's typically where the conversation then begins, like, something seems off about this. Maybe we should pause and think about this patient differently than the other 40 we're seeing in the office today.
>> Debra Schindler:What might be that thing that seems off, Dr. Higgins, that would have you call Dr. Kem?
>> Dr. James Higgins:Yes. there are some characteristics, like I mentioned, that are super typical. And we can tell from across the room what the nature of the bump is. But I would say if the distribution of it is somewhat unusual, if there are surrounding masses that would indicate lymph node enlargement, if the way that the skin overlying the bump was behaving, was either ulcerated, meaning slightly opened, or seemed to demonstrate changes that were atypical, that would be concerning. And that would lead us to saying, okay, it's really important for this next step to be carefully made. We can't just assume that it's probably the commonplace bump and we're going to treat it just like the commonplace bump. We need to make sure that we either image it ahead of time or take a tissue sample in a very thoughtful manner that sets the stage for us being prepared for whether it's, something that is more dangerous or very common and, benign. And we just over seemingly overreacted. So this is where the collaboration and I think the key message is. Our hand center has a huge staff with 14 full time hand surgeons, a number of specialists that collaborate. And from the standpoint of tumors, we collaborate with our musculoskeletal oncologist. And this is an invaluable relationship because if you were in a situation where you were a hand specialist unable to treat complicated cancers, then you would have a patient in your office where you may make mistakes in the first one or two steps of diagnosis or treatment, they could have really impactful problems for that patient in the future. So it's a point of pride for me that we have this capability of, collaborating with our colleagues in the MedStar system. And Dr. Kariem is a great example of that because, particularly for the musculoskeletal oncology piece, if we See, something like that, it's actually smart for me to say, hold on a minute. I'm not even going to make the next move right now. I want you to see Dr. Cream first so that we can both put our heads together and decide what that next move is. In fact, just today, I saw a patient in the office who had a very concerning, mass on the back of her hand. And it is quite clear that this is something that needs further imaging biopsies. We need to proceed very carefully. And it would be foolish for me to say, well, I haven't seen this enough times to be certain, but I'm going to take an educated guess when I know I can turn to my colleague, Dr. Karim He's seen it multiple, multiple times and knows with great certainty and experience what the next best move is. So this gives us the confidence to be able to take on all these patients and say we can deliver the best care anywhere for your problem, regardless of diagnosis.
>> Debra Schindler:So what will be the next step for this patient that you saw this morning? You're bringing Dr. Kariem in on it. Will you meet with her together?
>> Dr. James Higgins:Well, it's timely that you say that, because he hasn't seen her yet, and I just saw her this morning, so I'm waiting for that answer. But, I would say it would be great if we could see it, the patients together. The timing of that would require us both being in the same office at the same time. So in this particular situation, he is going to see her in the office in the next few days, and then we will likely, make decisions about imaging going forward and see what the best next step is for her.
>> Debra Schindler:Now, I've heard you say, first, you have to be very thoughtful on the next step. And then I heard you say, you have to be very careful, and I thought you were referring to int taking a biopsy. So is that to say that if this was a malignant tumor, you wouldn't want to do an aspirate or something that might risk it spreading? Is that the concern?
>> Dr. Mohammed Karim:Right. Exactly. I think that's a great point, Deb. And Dr. Higgin says, what do you do when all of a sudden, Dr. Higgin says, something is out of the ordinary here. He's concerned about it. And exactly as he had mentioned, the next step is almost always to get imaging, and that imaging is almost always in the modern era on MRI with dye, almost invariably. And that gives us a really good sense of where this mass is, and it gives us some initial clues as to what it might be. Even still, we see a lot of, benign lumps of fat, for instance, lipomas. And we can diagnose those pretty easily by mri. And when it's not a lipoma and it looks different on the m mri, we go, I don't know what this is. The most common thing I'll tell patients and hand surgeons is this mass has indeterminate imaging characteristics. I cannot make a diagnosis based on the mri. So the most appropriate next step is to proceed with a biopsy. So the first step is to get an MRI so we know where this thing is with tremendous intricate detail to get an initial sense of its tissue characteristics. And then almost always, unless it's a lipoma or a cyst, which we can tell by mri, it'll typically be to proceed with a biopsy. And that biopsy is in the modern era, usually done by an interventional radiologist with imaging guidance. So we would call that a needle biopsy, and that is a core needle biopsy rather than an aspirate. So most tumors that occur in the hand and anywhere in the musculoskeletal system are actually solid tumors. So rather than putting a small fine needle and just trying to aspirate, some fluid, rather than a solid core of tissue needs to be removed from that tumor. That's called a core needle biopsy. And there's a specific technique to do that, that are interventional. Radiology colleaguesout, the world, including at MedStar, are quite skilled at doing so. They'll pick the right imaging modality. So they may say, let's use ultrasound, let's use X ray, let's even use ct. I've had two patients this week in the upper extremity who have had CT guided biopsies of, various masses around the hand and arm, done by our interventional radiology colleagues. We actually collaborate on that in the sense that I will make that referral to them, and I'll ask them not just to biopsy the mass, but I'll tell them what route to take to biopsyinging it. For instance, we don't want to contaminate unnecessarily other compartments of the hand or arm through that biopsy. So I'm thinking to myself, if this does turn out to be cancerous, how am I going to remove it? And let's take this biopsy along the trackact of where we're going to be removing it if it is cancerous. If it hopefully turns out not to be cancerous, no big deal. We've still done the biopsy in a responsible manner. And so we often say that the biopsy should be done at the treating institution with the input from the treating surgeon. And that's a fundamental tenet of musculoskeletal tumor surgery, including in the hand. What we don't want is a poorly placed a biopsy that then compromises our ability to achieve hand or finger or limb salvage. For instance, if something is cancerous and that biopsy was taken in a way that crosses multiple compartments, all of that would have to be removed with that cancer. And that's disappointing cause that could have been avoided by just a well placed biopsy. So it becomes a close collaboration between a hand surgeon, a musculceeleal oncologist, and the radiologist who's doing the biopsy. Not to mention then the pathologist who us to interpret that. And coming back to Dr. Higgins point, those are all the components that we are proud to have here at MedStar. literally each of our hospitals, we've got, hand surgeons, orthopedic oncologists, even if not physically, they reviewing cases and then working as a team across the MedStar system to get these needle biopsies done and then, interpreted by our pathologists in a rapid fashion so we can get back to patients with answers as to what their next steps are. As Dr. Haiggins knows, and as I know, these are some of the most anxiety provoking visits for patients. That's my entire career. but it's just a tremendous amount of anxiety for people. So one of the things I take great pride and besides doing a good job is doing it expediently for people. these are patients who do not want to be waiting weeks and weeks on end. And so we get people in for tests quickly and we get them results rapidly so they know what to expect next.
>> Debra Schindler:Is that because they're afraid of it spreading to other parts of the body or are they afraid of losing their hand?
>> Dr. Mohammed Karim:I think it's all of that. I think it's all of that. I mean, just the fear. If you see a, world class hand surgeon and all of a sudden he or she goes, something about this isn't right.
>> Debra Schindler:Right.
>> Dr. Mohammed Karim:And they're referring you to an oncologist. All of a sudden the word cancer starts to swirl in your brain when you probably weren't even thinking that. Going to see somebody, that's remarkably stressful. Then they're sitting in my waiting room stressed out, saying, do I have cancer? And then we're trying to help them understand. Maybe, maybe not. But we'll get them there. And then if they do think they have cancer or if they are diagnosed with cancer, all the things that you're talking about, they do want timely treatment. All that is important.
>> Dr. James Higgins:Yeah, this is a really important part of care delivery, I think, is, we talk about the technical aspects and where should the biopsy be done and how to rebuild problems after cancer is removed. But from the patient standpoint, absolutely would echo this is. The expediency of the treatment is super important. Nothing irks me more than to find that a biopsy was performed and people are waiting weeks to hear the response, even if the report may be available. For my career, it's been a big priority as, to call patients a moment. The results cross my desk now not for routine tests like X rays, but when there is an issue, concern for cancer that needs to be given to the. Otherwise, I can imagine them sort of lying in bed at nighting at the ceiling, wondering what's going on? What's going on? And that anxiety builds and builds and.
>> Debra Schindler:Absolutely.
>> Dr. James Higgins:So absolutely a patient that is at peace with their diagnosis and treatment and feels confident their surgeon and their team is going to do better than someone who is not. I think that's a very obvious reality in medicine.
>> Debra Schindler:Now when the surgery is performed, are you guys doing that together?
>> Dr. James Higgins:If it is not safe to rebuild all once, then we obviously wouldn't. But, yes, we can work together in the same setting at the same time and get the patient's care done. Stem to ster.
>> Debra Schindler:If a biopsy comes back and it's malignant, is that a primary cancer of the hand or is that having spread from somewhere else in the body?
>> Dr. Mohammed Karim:That's a great question, Deb. And both things are possibilities. So we do have metastatic tumors quite uncommonly to the hand. However, it's much more common to have, for instance, a lung cancer, breast canc cancer or prostate cancer spread to the bones of the body. And usually they're closer to the middle or the core of the body. So for instance, the hip joint, the knee, even the shoulder. Those parts of the body are just closer to the main blood supply, so the tumor cells tend to land there. It would be unusual to have a metastasis that's spread all the way to a finger or even to the wrist. Not that doesn't happen. It certainly does, but it's just very, very unusual. If you have a bone or a soft tissue tumor in the hand that's malignant, it most likely has started there. Now, the most common soft tissue tumor in the hand, if we wanted to call it that, Would actually be a skin cancer, Like a squamous cell carcinoma or a melanoma from sun exposure. And those kinds of things, if you wanna lump those into the same category and one layer deep to the skin, Become all the soft tissue cancers. Those are primary cancers that have begun in the soft tissues of the hand, and we call those sarcomas. The most common sarcoma in the hand is a synovial sarcoma. But there are many different types. And then they can also even have bone tumors, believe it or not, that start in the, hand and the wrist. Those can be things like osteosarcomas, chondrosarcomas. Again, remarkably rare, but they certainly can happen.
>> Debra Schindler:What's a Ewing sarcoma?
>> Dr. Mohammed Karim:Right. A Ewing S Sarcoma is the third type of bone sarcoma. So there's three types of bone sarcoma, osteosarcoma, chondrosarcoma, and Ewing S Sarcoma. These are three different types of cancers that get in the bones anywhere in the body, actually. But that includes the hand and the wrist.
>> Debra Schindler:So the, cancer of the hand, it just sounds strange saying hand cancer, Right? But does that mean chemo and radiation and other courses of treatment that would be normal for other cancers?
>> Dr. Mohammed Karim:Great question. It depends on what kind of a cancer it is, in fact. So if it is, for instance, something like a melanoma, for the most part, that's treated with just removal surgically, and then making sure that it hasn't spread anywhere else. Certainly if it has spread somewhere else, Then things like chemotherapy or immunotherapy come up. Then it becomes specialized to specific type of cancer. So, for instance, chondrosarcoma is a type of cancer that starts in the cartilage, and that cancer is treated exclusively with surgery as well. Osteosarcoma is a type of cancer treated with both chemotherapy and surgery. And then if you have somebody with a soft tissue sarcoma, Such as a synovial sarcoma, about the hand, not in the bone, but in the fleshy parts of the hand, those are treated with a combination of surgery and radiation. So, we bring on radiation oncologists who give radiation, Medical oncologists who give chemotherapy or other systemic treatments, and then a surgeon like me who removes tumors, and then, very importantly, a plastic or reconstructive hand surgeon who can work to fix the deficit that we create from removing the cancer.
>> Debra Schindler:Have you had to do that. Dr. Higgins?
>> Dr. James Higgins:Yes.
>> Debra Schindler:Any stories for us? hope.
>> Dr. James Higgins:Yes, Give us the story. The collaboration here, and this is. We spoke earlier about how important it is to make the first steps correctly, but it's true. Every step along the way is super important to focus on. Be thoughtful about. The reconstruction is the word that we use for rebuilding the arm or limb or hand or digit after we remove the cancer. So certainly when the cancers are removed, there's a need to remove the cancer itself, but you also need to remove surrounding tissue. And this is normal tissue. And you might say, well, why would you remove normal tissue? Well, we want to remove normal tissue so that we can conclude with some margin of certainty that we have taken out all of the cancer. So that means that in the end of treatment of a cancerous mass, that there is normal tissue that's missing. And as much as we can celebrate the fact that we've successfully removed the cancer, we now have to replace that tissue and restore function. And so that can be done in many, many ways, but generally we have to replace the tissue types that are missing. So if it's bone that was resected, we'll be replacing bone. And if it is muscle that's resected, we may be replacing muscle. Likewise skin, subutaneous fat, tendons, even nerves in some cases.
>> Debra Schindler:All from the patient.
>> Dr. James Higgins:Yes. So we will most often use the patient's own tissue. The reason for that is that in most cases, it heals quickest. If it's your own tissue, it also is tissue that you do not need to be. Say, for example, we're all familiar with the concept of transplantation, like solid organ transplantation. In those cases, those patients need to be immunocompromised in order to tolerate other patients'tissue so we generally don't do that for reconstruction after cancer. But there are other ways for us to either use synthetic tissues or donated tissue that's prepared so that is tolerable for the recipient. But in general, we use the patient's own tissue. And when we do that, that would require boring from somewhere else. So we have, I would say in a larger picture, we have more or less warehoused what aspects of the human body we can borrow tissue from at relatively low cost, meaning it's expendable or removable, without a functional, problem, where we take the tissue so that we can use that as sort of spare parts to rebuild a deficit created by a cancero resection. So that sounds very vague, but, for example, if one were to have a Cancer that would require removing, bone, tendon and muscle, say for example, in the hand. We could rebuild the bones using bones from other parts of the body. We sometimes borrow from the tibia, sometimes from the fibula. These are lower leg bones. You can even borrow bone from the hip bone. Likewise for skin. If there's now a, imagine a circular wound that's a large wound that can't be closed and pulled together, then we'll need to move skin from somewhere else. And oftentimes we're doing this as a, procedure where we're moving it with blood vessels. This procedure requires us borrowing that tissue from somewhere else, moving it into the wound, sewing it closed, but then connecting arterial supply and venous drainage, meaning hooking up very small blood vessels. Sort of like miniature plumbing, using a microscope so as to keep that tissue alive. That field of reconstruction is complicated and is something that has evolved over the last several decades to what I think now is, is a state of reconstruction where we can generally replace tissue very, very reliably with success rates that are extremely high in the 98, 97% range, so that the patients in one hospital stay can go home with a closed wound, reconstructed bones, and an opportunity to move forward with healing and rehabilitation. If you look back to a, time prior to our ability to move, transfer tissue around the human body, generally speaking, the wide resection of a tumor would result in patient requiring an amputation, meaning so much tissue has been removed from the limb that the remaining tissue or the size of the wound that results is, something that you can't heal, and thus would result in an amputation. So we are generally trying to avoid amputations in trying to move towards reconstruction if we think it's feasible.
>> Dr. Mohammed Karim:That's such an important thing to emphasize, as Dr. Higgins is saying. I mean, the reconstructive aspects of saving somebody's hand in extremity are a field in and of themselves, a life devoted to doing that with 97, 98, 99% success. That's what I have the benefit of the Curtis National Hand center to achieve for patients with hand tumors. It's remarkably helpful for me as a surgical oncolog to be able to focus on removing the tumor and focus on my goal, which is to remove this tumor in its entirety with a curative intent for that patient without having to directly worry about the function of their hand. Because I've got a world class hand surgical team who can put back together basically any deficit that I create for them. And that synergy is critical for the Patient to have a good outcome. I can focus entirely on the cancer outcome. I can remove whatever I need to remove to give this patient the best cancer related outcome without my energy and thoughts being focused specifically on the reconstructive aspects. Because there's another surgical team dedicated to that. That may sound obvious, but that isn't always the case. It's easy for a surgical onco callist to say, well, gosh, I really don't want to cut that nerve. I don't have have to cause their hands not gonna work well. But you're also seeing the tumor get close to that nerve, and maybe you're thinking about, am I gonna skimp on that in some way to get their hand working? But then you've compromised their cancer outcome. I don't have to worry about that. Dr. Higgins is here to put this hand back together. However, this patient needs to make it work. I focus on what I do well, and he focuses on what he does well. And that is literally happening together in the operating theater. And it results in the best outcome, for the patient.
>> Debra Schindler:I can see how comforting that would be for a patient to come and see both of you with skill sets together. After a patient has surgery and gone through cancer treatment, is there a risk that the tumor could come back again or could it come back in their other hand?
>> Dr. Mohammed Karim:That's a great question, Deb. Yeah, absolutely. And after the treatment is complete, and again, we're talking about curative resections for primary tumors occurring in the hand and upper extremity, not metastases. for those patients, after the treatment is complete, we enter a so called surveillance mode. And in that mode, what we're doing is we're watching for exactly what you just said, is the tumor coming back. We look at two places, we look at the place where the cancer had started, and we try to see is that cancer coming back in the same place. We do that by physical exams, physically looking at the patient in the area to see if it's coming back, feeling the area. And in this era, we'll typically get MRI scans, and we'll often do that at some interval of time, every three to six months. Perhaps get retutine M MRIs and do physical exams to see if the tumor is coming back in that same area. Depending on what kind of tumor it is. Most sarcomas tend to spread to the lungs first if they're going to spread. So we do tend to scan a patient's lungs with CAT scans in that same interval every three to six months to make sure it's not coming back. And so it really turns into a long term relationship. And we are, in fact keeping an eye on our patients. Dr. Higgins is keeping an eye on the patient in terms of how their hand is doing and how their quality of life is doing, how their function is doing. And then I'm keeping an eye out to make sure that that tumor is not coming back. That could require additional treatment for a.
>> Debra Schindler:Patient to be at that kind of risk. Do you think it's genetic or environmental?
>> Dr. Mohammed Karim:Great question. So it depends on the type of tumor again. So I think, again, for skin cancers such as melanoma, squamous cell carcinomas, basal cell carcinomas, very clearly sun exposure is, associated with those kinds of skin cancers. For sarcomas, however, we don't have a clear environmental or, believe it or not, genetically. So there basically are unfortunately, sporadic mutations or sporadic bad luck that leads to them. There are a few genetic, predispositions that are again, incredibly rare. Where there are some families that are known to have certain types of sarcomas occur more frequently, but that's a tiny minority. The vast majority of sarcoma that I see, are just essentially bad luck. that happened.
>> Debra Schindler:I'm going to back up a minute. You mentioned before leipomas, and I know you had a patient recently that had a very large lip pama on his hand, correct? Tell me about that. What do people need to know about a lipoma and if they suspect maybe they have a lump on their hand, what would they be looking for?
>> Dr. Mohammed Karim:If it's a lipoma? Yeah, it's a great question. and you know, lipomas are typically soft. They're squishy, frankly, in the way they feel. They're typically not firm, hard or painful in any way. But to be totally frank, those are very non specific features. There are a lot of cancers also that are soft, fleshy, and don't hurt. That's actually a common misconception. folks will think that since it doesn't hurt, it must not be cancerous and actually could not be further from the truth. The vast majority of cancerous tumors do not hurt. For that particular gentleman who had a big lipoma on his hand, a nice guy in his, 30s who has had this tumor for many, many years. We think it may have been related to trauma in his childhood. Not any big trauma, but maybe just incidental trauma like any kid has playing around outside or something like that. And he's had the slowly enlarging mass for many years. In fact, I met him and I met his wife. And they showed me pictures from when they first started being together and then from their wedding. And I can see that this mass was there on those photos, but had clearly been increasing in size. And things that are increasing in size, I always worry about, could be potentially cancerous. So, you know, when we met that man, we did all the things that we spoke about. We got an mri. The MRI suggested that this looked like a fatty tumor. Most fatty tumors are benign, their lipomas. But the fact that it was growing in size, was somewhat concerning to me. So I actually had our radiologists to do a biopsy of that. On that biopsy, they were able to confirm that it was a lipoma, do some advanced molecular testing, which is great. And then we took that patient to the operating room to remove that benign lipoma. As a team, both myself and a hand surge at the Cururtis National Hand center work together to remove that tumor successfully for that patient who's now.
>> Debra Schindler:Going through recovery in one surgery.
>> Dr. Mohammed Karim:in that case, we chose to do it in two surgeries, as Dr. Haigns had alluded to. Sometimes we choose to do that for any of a number of reasons. Sometimes it can be for, we say, oncologic purposes. We want to make sure that we so called got it all. And we don't want to have Dr. Higgins or his colleagues do a beautiful reconstruction and then find out a week later that, ah, there was still one cell over in a corner somewhere. We want to be darn sure. Sometimes we actually pause and literally put a special kind of a bandage on and just wait and give the pathologists a week to confirm things. Other times, it may not even be oncologic. Other times the reconstructive surgeon may turn to me and say, hey, you know what? Now that I've seen what you've done, let's plan for this kind of a reconstruction. And we'll do that in a week or so, just depending on what's going on. Sometimes it's hard, you know, for a reconstructive surgeon to plan the reconstruction without seeing the deficit that I've created from the resection yet. We have ideas, we meet the patient ahead of time, and we share with them, in fact, that we're not going to have a good sense of the reconstructive plan. We, we have A through E, but we don't know if it's going to be B, C OR D Until Dr. Kariem does what he's going to do with things. So there's sometimes we choose to do it in a staged fashion, so to speak, for patients.
>> Dr. James Higgins:Collaboration also allows for some intraoperative changes to be feasible. Meaning if you sensed that the resection, meaning the margin of where the tumor had to be removed was in one place, and you found upon exploration that you needed to take more tissue, that would result in a different challenge for reconstruction. But knowing that the reconstruction is available and that we can rebuild those things does enable us to not compromise and, say, limit the resection. It frees up the hand of the oncologic surgeon to resect as much as is needed to give the patient the most certainty of surgical cure. And that's important. There could certainly be situations where, if there was no ability to reconstruct the wound, one would have to weigh the risks and benefits of boy, if I take what is required here in order to achieve tumor removal and cancer cure, it may result in an amputation or it may result in a defect that I can't rebuild. So the collaboration here really helps the surgeons and absolutely helps the patient.
>> Debra Schindler:A defect that you can't rebuild because of, as you suggested before, Dr. Cream, maybe it's too close to a nerve and you have to cut through a nerve or something like that.
>> Dr. Mohammed Karim:Yeah, these are all critical things. You know, the hand is an intricate place with so many critical structures running right by it. And again, I need to focus on how do I get this thing out, and I don't spill any cancer cells in the along the way. If that tumor sitting next to a critical nerve. Again, the only variable that I have as a surgical oncologist is my ability to remove the tumor in its entirety and not leave any cells behind. If that means cutting a nerve, that means cutting a nerve. And that means turning to my reconstructive colleagues to say, cutting this nerves is what I need to do. What can we do to give this person a hand that'still work well for them?
>> Dr. James Higgins:And in some cases, that's nerve grafting and rebuilding the nerve. In some cases, it may be other maneuvers, such as is doing tendon, we call them tendon transfers that restore function without having the activity of that nerve or the function of that nerve present. So there are many different ways of trying to replace structures, and it may not be replacing it with the same structure. There are numerous tricks that enable us to replicate function without making it identical to the initial structure.
>> Debra Schindler:I would like to hear, because you guys are very interested and you have really extraordinary cases that are unique. What is the most unusual or memorable hand tumor case that you've had. Do you have one?
>> Dr. Mohammed Karim:I think two things. Two things that I'm really proud of. The Cururtis National Hand Center's ability to reconstruct. One are bone vascularized bone grafting in particular. Dr. Higgins field of expertise. Sometimes we encounter patients who have malignant tumors of the bone of their wrist. The major bone in the wrist is a distal radius. Distal meaning end of. And, the radius is the major bone in the wrist. So are distinctly. Remember taking care of a lady who had a chondrosarcoma, which is a malignant tumor of cartilage in the distor radius in her wrist bone. So her entire wrist bone needed to be removed. In fact, it was in the joint of. Well, so the entire wrist joint needed to be removed on block, meaning as a single piece so as not to spill any cancer along the way. So that's quite the devastating operation to remove somebody's wrist bone and wrist joint altogether. You start to wonder about things like do we need to just amput this hand at that point or can we do something to reconstruct that? And Dr. Higgin can speak to this better than I can, but certainly these are. There are things that can be done to reconstruct that. For instance, the fibula bone from the leg can be brought up along with its blood supply. And that can be brought up to either restore the wrist or at least to restore the hand with a fused wrist in a reasonable position. And that's where those kinds of collaborations critical what we would have amputated need not necessarily be amputated because of vascularized bone grafting, for instance.
>> Dr. James Higgins:Yeah. And the fibula, this, bone from the lower leg that we use for often spanning defects in the wrist area. This is a great example of warehousing something expendable elsewhere. So the area where the fibula is taken from is your lower leg, where there are two bones. And we rely on the tibia, the adjacent bone, to provide support for the leg. So we can now actually remove that second bone from your leg and you are permitted and able to walk immediately thereafter. And that bone with its blood vessels can be moved up into the wrist used to span a defect. So let's say imagine the bone that was removed in order to cure the cancer was 3, 4 inches in length. We could span that entire defect by putting in the fibula from your leg, putting plates and screws on both ends as if treating a fracture, and then connecting the blood vessels that are attached to the fibula. To blood vessels that are in your wrist, so that arterial blood circulates in and venous blood circulates out. And now that bone lives in its new location. So the fibula bone used to be down in the lower leg, and now it moved up to the arm and has similar blood supply. Feels as if it's always lived there, but is now doing a completely different task and being much more critical, because in this location now, without the fibula being there, the wrist would be unstable. And in many cases, one would consider an amputation.
>> Dr. Mohammed Karim:And I can't tell you how invaluable that is As a surgical. As an orthopedic oncologist and as a spinal oncologist. The ability for us to take a living bone and transplant it into different parts of the human body Is just so critical to be able to get tumors out and still keep lim. So the wrist is an example. The knee I'm actually seeing this afternoon, a young man, 22, who's got osteosarcoma at the top of his tibia bone that I'm gonna have to remove that. And one of the ways we can reconstruct that is potentially using the fibula bone and bringing that up in the spine. Sometimes I need to remove a malignant tumor from the spine. The entire vertebra has to come out. And we've come to learn that the fibula bone can actually be transplanted up to the spine. So it's such a useful bone to be able to move to different parts of the body and to be able to have the expertise of a hand surgeon, but really a reconstructive surgeon to reconstruct bony defects that I create anywhere in the body. Absolutely invaluable.
>> Dr. James Higgins:Yeah. Another great and very interesting example, when we have defects that are encompassing the majority of the thumb, know, we obviously think the thumb is of critical importance for opposition. We, can actually replace the thumb, using a toe. Something that we can do with confidence and again, deliver a 97, 98% success rate with rebuilding your entire thumb with great toe. Which sounds, I'm sure, to listener'hard to imagine. Maybe, when we speak of moving your fibula to your wrist, that sounds like, okay, maybe that could work. But now you're trying to imagine your great toe moving into your thumb position. But we actually have the ability to trim down the great toe and make it look remarkably like a thumb. And its functional capability is. It's one of the best operations we do from the standpoint of in a single sweep, increasing a patient's function is to restore thumb function.
>> Debra Schindler:that is remarkable.
>> Dr. James Higgins:Yeah.
>> Debra Schindler:That's not to get off subject, but when you do that with a child and it still grows, that's always been amazing to me that it could still grow with the child's hand and arm.
>> Dr. James Higgins:Right. And this is the benefit of restoring blood supply using the patient's own tissue. It's as if that part, when you move it from its original home and move it to a new position, once the blood supply is restored, it can regain its normal growth pattern and heal just like normal bone would heal and become integrated into the hand.
>> Debra Schindler:Both of you have such a unique, high level, of specialty skills, really, dynamic duo. What is your final advice for anyone who is listening who has an undiagnosed lump or tumor in the hand?
>> Dr. James Higgins:Well, I would think that the first thing is you need some peace of mind. And that is something that we can provide you. Because I think people will often say when they come in the office, doctor, I know you take care of some complicated things, but, and this is probably nothing. I've heard that so many times, and I say, well, well, to you, it's really important. There's a bump that you've never recognized before, and that's concerning and can give people a moment's pause. So all of those visits are important to us, and they are, important particularly to the patient. So if it is something that you are concerned about, you should absolutely come see a hand surgeon, and we'd be happy to take care of you even in the simplest situations, when it turns out to be something really simple, benign, a Bible bump, as you said earlier. And I say you can go home and rest assured that's nothing to worry about. That's a worthwhile intervention. And in that way, we feel like we've made a difference for the person, even if we don't do an operation.
>> Debra Schindler:Oh, absolutely. You can't understate the importance of peace of mind.
>> Dr. Mohammed Karim:Absolutely. And, to echo Dr. Haiggin'point from early in our talk, when and if, unfortunately, you are faced with that difficult situation where there is something cancerous or questionably cancerous, know that we're here to help, and we have the experience and knowledge and ability to guide you through one of the most difficult times of your life safely and effectively, and we will get you through this.
>> Debra Schindler:my husband may not trust my armchair hand surgeon skills, and I may have to send them to you guys. And I thank you both.
>> Dr. James Higgins:He welcome to come on in. Absolutely.
>> Debra Schindler:Thank you both for sharing your expertise with us here on MedStar Health doctalk do if you have concerns about a hand tumor and would like to see a specialist, call 877134 Ortho. Thats 877-346-7846. If you'from outside the Maryland region, ask for a video consulte appointment. If you would like to provide feedback on this podcast or get information on hand tumors, send me an email. Debra Schindler medstar.net.
