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Tumors and Tumor-Like Lesions of the Pediatric Hand and Wrist: Clinical Presentation and Risk Factors for Malignancy
Akbar N Syed, MD, David Kell, BS, Pille-Riin Värk, MD, Alexandre Arkader, MD, Sulagna Sarkar, MS and Apurva S. Shah, MD MBA, The Children's Hospital of Philadelphia, Philadelphia, PA

Introduction: Malignant tumors of the pediatric hand and wrist are rare. We hypothesize that pain, large size, and palm/wrist location are risk factors for malignancy in children.

Methods: Patients <19 years of age presenting with hand and wrist tumors or tumor-like lesions from 2008-2022 at a single tertiary-care children’s hospital were identified using CPT and ICD codes. Patients with skin lesions, commonly encountered subcutaneous masses (lipomas, ganglion cysts, and sebaceous cysts), multiple hereditary exostosis, and Ollier disease were excluded. Data collected included demographics, clinical presentation, imaging features, and surgical management. Risk factors for malignancy were determined using receiver operating characteristic and descriptive statistical analysis.

Results: 327 tumors and tumor-like lesions were identified in 312 patients, with a mean age of 10.1 ± 4.6 years (Table 1). 315 (96.3%) lesions were benign, and 12 (3.7%) lesions were malignant. Most common benign bone tumors were osteochondroma (75/160, 46.9%) and enchondroma (50/160, 31.3%), while most common benign soft tissue masses were vascular malformation (39/155, 25.2%) and giant cell tumor of tendon sheath (30/155, 19.3%), all located most commonly in the digit. All malignant tumors (3 bone, 9 soft tissue) were located in the palm or wrist. Epithelioid sarcoma (4/9) and synovial sarcoma (2/9) were the most common soft tissue malignancies and osteosarcoma (3/3) was the only malignant bone tumor. Overall, most common presenting complaint was swelling (63%) and pain (19.9%) while the primary reason for surgical intervention was pain (30.3%). Among benign lesions, 85.4% (269/315) underwent excision/curettage with a recurrence rate of 7.8% (21/269). Size >11.4 mm (p<0.001) and palm/wrist location (p<0.001) were risk factors for malignancy. ROC analysis showed age and pain ratings as poor predictors of malignancy. Among bone tumors, aggressive zone of transition, periosteal reaction, and cortical destruction were radiographic risk factors for malignancy (all, p<0.001). (Table 2)

Conclusions: Most common tumor/tumor-like conditions of the pediatric hand and wrist include osteochondromas, enchondromas, vascular malformations, and giant cell tumor of tendon sheath. Tumors sized >11.4 mm and tumors located at palm/wrist likely represent malignancies and should be approached with caution. Overall recurrence rate following excision of benign pediatric hand and wrist tumors is low.

Tumors of the Pediatric Hand & Wrist Table 1.jpg
Tumors of the Pediatric Hand & Wrist Table 2.jpg
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