The Results of Treatment of Two Hundred and Seventy-Three Carcinomas of the Hand
C. R. W. Rayner
T H E RESULTS OF T R E A T M E N T OF T W O H U N D R E D A N D
S E V E N T Y - T H R E E C A R C I N O M A S OF T H E H A N D
C. R. W. RAYNER, Aberdeen
SUMMARY
S q u a m o u s c a r c i n o m a o f the h a n d b e h a v e s m o r e aggressively, a n d is m o r e
d i f f i c u l t to cure by non-surgical means, when it arises in the interdigital clefts or
adjacent s k i n o v e r the m e t a c a r p o phalangeal j o i n t s .
INTRODUCTION
Squamous cell carcinoma of the hand might easily be regarded as having similar
behaviour patterns to squamous carcinoma of the skin elsewhere in the body. The
specialized nature of the skin and the anatomical complexity of the hand suggest,
however, that there m a y be additional factors that require particular consideration
in planning treatment.
MATERIAL
The records of 273 patients with histologically proven squamous cell carcinoma
of the hand for the ten year period 1963-1972 have been reviewed. Only patients with
lesions distal to the prominence of the head of the ulna on the dorsum or distal to the
transverse flexor wrist crease on the palm were included.
RESULTS
The distribution of squamous cell carcinomas is shown in Fig. 1. Seven were on
the palm and the remainder on the dorsum. Only four of the dorsal lesions were
distal to the proximal interphalangeal joint. The sex ratio was four males to one
female; despite this, in only sixteen cases were predisposing factors noted and this is
not considered to be due to under-recording, as an enquiry for causative factors was
a regular part of patient assessment. Only in five cases were there multifocal actinic
c h a n g e s - - a reflection of the climate in Manchester. No patient was under forty
years, and 80~ were over sixty years of age.
Surgery
Of the twenty-four cases treated electively by surgery, eight had amputations
and sixteen had excisions and skin grafts. Twenty-three of these lesions arose in the
region of the interdigital clefts. Five died of metastatic disease. Twenty-four o t h e r
patients had " u n p l a n n e d " surgery, that is, the operation could not be regarded as a
formal attempt at cure. The , o p e r a t i o n " consisted of excision and direct closure or
curettage. The only two of these patients with lesions in the cleft area died of
metastases as did four others with lesions elsewhere on the dorsum.
Radiotherapy
Two hundred and twenty-five patients were treated electively by radiotherapy.
Radioactive elastoplast moulds of gold or radon seeds controlled the primary lesion
in 93~ of cases. External beam therapy was used when it was technically impossible
C~ R. W. Rayner, M.S., F.R.C.S., Woodend General Hospital, Aberdeen.
This paper was submitted from the Christie Hospital, Manchester.
9 1981 British Society for Surgery of the Hand 0072-968X-81-00290183 $02.00
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The Results o f Treatment o f Two Hundred and Seventy-Three Carcinomas o f the Hand
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to use a mould in twenty-one cases, and had an overall failure rate o f 52%. This
reflects the technical difficulties of irradiation in the interdigital clefts. Significant
radionecrosis occurred in sixteen cases (fourteen in relation to the interdigital clefts).
O f these, a quarter (four) contained active disease four months after treatment
finished (Table 1)
TABLE 1
RADIONECROSIS
Total patients treated by radiotherapy
Total radionecrosis
(Radionecrosis in "danger area"
(Radionecrosis elsewhere
Recurrence in radionecrosis
Recurrence in radionecrosis in "danger area"
275
16
14)
2)
6/16
4/14
Amputations
Twenty-two patients required amputation. In eight patients, it was the primary
treatment of choice and in fourteen after radiotherapy. 90~ of these were related to
lesions in the interdigital clefts.
Metastases
Twenty-eight patients (8070) developed metastases but seven were alive and well
at five years. O f the twenty-one who died of metastases (607o of total), eighteen had
local node involvement but three had none. Six patients with axillary metastases
were treated with radiotherapy alone and all died within one year. Although six
patients presented with metastases, two of these were alive and well at five years.
Danger area of the hand (Fig. 2)
O f the two hundred and seventy-three squamous cell carcinomas treated, either
surgically or by radiotherapy, fifty-six behaved in an aggressive or complicated
manner, by failing to respond to radiotherapy or surgery, or requiring primary
amputation or presenting with metastases.
When the anatomical site of these aggressive or complicated lesions is analysed,
it can be seen that thirty-four out of the eighty-six lesions treated in the area of the
t h u m b web space, the interdigital clefts or proximal phalanges came into this group;
that is, 40070 of all the lesions treated in this area and 6407o of all the aggressive
lesions. Furthermore, all seven cases o f severe radionecrosis requiring amputation
occurred here. On the remaining dorsal areas, only eighteen out of one hundred and
seventy-six behaved aggressively (10070) and o f these four were inadequately treated
surgically before referral to the Christie Hospital. If these four are removed, then
the figure falls to 8070. The proximal phalanges, clefts and thumb web could perhaps
be called the " d a n g e r z o n e " of the hand. On the palm four out of seven cases
behaved aggressively.
If the means of treating the lesions in the " d a n g e r z o n e " are examined, it can be
seen that local recurrence occurred in 2007o of cases treated with a radioactive mould,
52% with external beam irradiation and 13070 with excision and grafting. These
figures do not compare the effectiveness of different treatments statisticaly but serve
to emphasize the difficulties of treatment by any means in this area.
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The Results o f Treatment o f Two Hundred and Seventy-Three Carcinomas o f the Hand
C. R. W. Rayner
DISTRIBUTION OF 'AGGRESSIVE' LESIONS
TOTAL TREATED
,!~
/'AGGR ESSIVE'
RADIONECROSIS
86
34 (40%)
l
(8%)
REATED 176
;IVE
~[VE +
2LOSURE
14 (8~,)
4
: I WERE ' AGGRESSIVE
DISTRIBUTION OF S CC
HAND
'DANGER AREA' OF HAND
Fig. 1. The distribution o f s q u a m o u s cell carcinoma of the hand.
Fig. 2. The distribution of "aggressive" s q u a m o u s cell carcinomas of the hand. The area of the
interdigital clefts and proximal phalanges constitute the " d a n g e r a r e a " of the hand. Note that in
the t h u m b web the area extends proximally between Extensor Pollicis Longus and the index
extensors.
DISCUSSION
Kendall (1971) reviewed seventy-three patients with squamous cell carcinoma of
the hand and recommended excision and graft as the treatment of choice. They
recommended radiotherapy only for special cases. They did not, however, identify
the interdigital clefts as an area of special " d a n g e r " . Outside this area, radiotherapy
is as safe as surgery (96% cure rate) but surgery is quick and simple. Outside the
"danger area" the treatment can reasonably be left to the patient's choice. It must
be emphasized that the results in this series cannot be used to compare the relative
merits of surgery and radiotherapy; it should be noted, however, that the twentyfour surgical cases (twenty:three in the "danger area") were referred by
radiotherapists for surgery as the primary (elective) treatment. Petres (1974)
recommended excision and direct closure or local flap repair, but the experience
with excision and direct closure in this series resulted in four (out of twenty-four)
patients with lesions in the " s a f e " area of the hand dying of metastases. If a flap is
necessary because there is no favourable bed for a graft, due to joint, tendon or
bone exposure, then it is likely that soft tissue infiltration is so extensive that
amputation should have been performed.
Lesions arising in the "danger area" seem to show more aggressive properties
from the outset than can merely be attributed to technical difficulties of
management. The six patients with metastases at the time of presentation all had the
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primary lesions in this area. Possibly the close proximity of highly complex tissue
planes to the skin surface and the massaging effect of digital movement has some
bearing on this.
Adverse prognostic features, in addition to the lesion arising in the "danger
area", are soft tissue induration and bone involvement. Histology is not a useful
guide to prognosis; two-thirds of the patients dying had differentiated lesions but
five out of seven survivors with metastases originally had poor histological features.
Squamous carcinoma of the hand is a disease
is necessary, this should be designed to give as
possible. The return of function is usually poor
display a disease-free part-hand that they may
previously.
of the elderly. Where amputation
favourable a cosmetic result as
but the patients are delighted to
have been at pains to conceal
Care should be taken over the diagnosis of Kerato-acanthoma on the hand.
Twenty-three out of forty-nine cases (44%) reviewed were found to be invasive
squamous cell carcinomas.
REFERENCES
KENDALL, T. E., ROBINSON, D. W. and MASTERS, F. W. (1971). Hand Tumors. Primary Malignant Tumors of the Hand. The Journal of Kansas Medical Society, 72: 376-379.
PETRES, J. and HAGEDORN, M. (1974) MOglichkeiten der Dermatochirurgie bei Neoplasien im
Handbereich. Fortschritte der Medizin, 92: 1054-1058.
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