Is a routine histopathological examination justified for all tumours resected from the upper extremity?

Abstract

Most lesions of the upper extremity are common and benign, and the need for a routine pathology evaluation of these specimens has often been questioned. This study aimed to evaluate the concordance of the initial clinical and final histological diagnoses of tumours which, based on clinical presentation and intraoperative findings, are most likely benign or malignant, and to answer the question whether or not a routine histopathological examination is justified for all tumours in the upper extremity.

Material and Methods We analysed the results of histopathological examinations of benign tumours resected in 346 patients and malignant tumours resected in 6 patients.

Results Our analysis showed a 100% concordance between the initial (clinical) diagnoses of the tumours as benign or malignant and their final histopathological diagnoses. Only in 12 cases (3.5%) of initially benign tumours did the clinical presentation and/or intraoperative findings raise doubts.

Conclusions The results of this study show that a routine histological evaluation of all tumours resected from the upper extremity is not justified and may be confined to selected cases in which clinical presentation and/or intraoperative findings raise doubts.

Zusammenfassung

Die überwiegende Mehrheit der Tumoren an der oberen Extremität sind gutartige Läsionen, weshalb die Notwendigkeit ihrer routinemäßigen histopathologischen Untersuchung oft in Frage gestellt wird. Ziel der Studie war es, die Konsistenz der initialen klinischen Diagnose und der endgültigen histologischen Diagnose bei Tumoren zu beurteilen, deren klinisches und intraoperatives Bild auf eine gutartige oder bösartige Erkrankung hindeutete, und die Frage zu beantworten, ob eine routinemäßige histopathologische Untersuchung aller Tumoren der oberen Extremität erforderlich ist.

Material und Methoden Analysiert wurden die Ergebnisse der Studie mit exzidierten gutartigen Tumoren bei 346 Patienten und bösartigen Tumoren bei 6 Patienten.

Ergebnisse Die Analyse ergab eine 100%ige Übereinstimmung zwischen der Ersteinschätzung der Tumoren als gutartig oder bösartig und ihrer tatsächlichen histopathologischen Diagnose. Nur in 12 Fällen (3,5%) waren gutartige Tumoren fraglich.

Schlussfolgerung Die Ergebnisse der Studie deuten darauf hin, dass eine routinemäßige histopathologische Untersuchung aller Tumoren der oberen Extremität nicht gerechtfertigt ist und nur auf Zweifelsfälle beschränkt werden kann.

Key words

Tumour - pathology - upper extremity - benign tumours - malignant tumours - histological examination

Schlüsselwörter

Gutartige Tumore - bösartige Tumore - obere Extremität - Pathologie - histopathologische Untersuchung

Introduction

Lesions of the upper extremity are common, with an estimated 15% of all soft tissue tumours found in the human body localised in the hand. Among all benign upper extremity tumours, ganglions are the most common (50–60%), followed by giant cell tumour of tendon sheath (15–20%), lipomas (10–15%) and rheumatoid nodules (10%) [1] [2] [3]. The risk of an upper extremity lesion being malignant is very low, less than 1% for both soft tissue tumours and bony tumours [4]. Nevertheless, the routine histological examination of most upper extremity tumours is considered a standard and a rule, except for some typical looking ganglion cysts, epidermoid cysts or Dupuytren’s nodules [1] [3]. A justification for this strategy is anxiety about overlooking malignant lesions among tumours presenting clinically as benign ones. However, a consequence of this approach is doing thousands of histological evaluations of lesions in which clinical presentation leaves no room for doubt that they are of a benign character. In these situations, the risk that the lesion is malignant is reckoned to be almost zero. One may claim that this is not true, because one per 100–200 resected lesions appears to be malignant. However, it does not mean that this one case presented typically as a benign tumour. Usually this 1% of malignant lesions presents as malignant or, at least doubtful, which obviously determines the necessity of their histological evaluation.

The risk of malignancy in tumours, which at first sight look benign, is not known, but both clinical practice and single data from the literature show that it is minimal [4] [5]. Therefore, doubts are raised about the necessity of routine pathological evaluation of lesions, which clinical presentation, imaging and intraoperative findings indicate are most likely benign. This especially concerns ganglion cysts, small lipomas, epidermal cysts, fibromas and enchondromas (bony tumour). In the authors’ institution, histological examination of these tumours is not routinely performed, unless its clinical or intraoperative presentation raises plausible doubts. Likewise, submission of other small, benign-looking tumours for pathological evaluation is frequently questioned, although rarely omitted. Clinical and morphological features of tumour, which presents no traits of malignancy, are shown in [Table 1]. By contrast, the features suggesting malignant character of the lesion are shown in [Table 2].

Table 1 Clinical and morphological features typical for benign tumour

Slow growth (increasing the size)

Mobility over sourrounding tissues

Normal appearence of the skin over the tumour

Presence of well-defined capsule

Table 2 Clinical and morphological features typical for malignant tumour

Fast growth (increasing the size)

Exophytic growth ([Fig. 2] [3])

Tumour immobile over sourrounding tissues or loss of mobility of until now mobile tumour

No well-defined capsule

Infiltration of sourrounding tissue

Presence of satellite tumours

Enlargment of regional lymph nodes

Destruction of bone (in bony tumours) ([Fig. 4b])

Another justification for submission of resected tumours for pathology evaluation is the need for assessing the completeness of the excision; namely, if the lesion was resected with an adequate margin of healthy tissue or, maybe fragments of the tumour were left in the resection line (incomplete excision). However, this concerns only tumours that have no well-defined capsule. Well-capsulated lesions are easy to enucleate in toto from the surrounding tissue, which warrants the completeness of the resection ([Figs. 1a, b]).

Fig. 1 a. Beginning of enucleation of the giant cell tumour of the tendon sheath from the little finger. b. Enucleation of the tumour cont. Note characteristic yellow-grey colour of the lesion.

The first objective of this study was analysis of the accordance of initial clinical and final histological diagnoses of tumours which clinical presentation and intraoperative findings indicate are most likely benign. The second objective of this study was analysis of the accordance of clinical and histological diagnoses of tumours which clinical presentation and intraoperative findings indicate are most likely malignant. Based on the results of these aims, the final objective was to answer whether a routine histological examination of all tumours at the upper limb is well-founded and justifiable.

Materials and Methods

Over a period of 3 years (from 2016 to 2018), a total of 346 patients were operated on in the authors’ institution with the diagnosis of benign tumour in the upper extremity. There were 234 women (68%) and 112 men (32%) at a mean age of 53 years (range 18–88). All these patients were admitted to the hospital with the initial diagnosis of “benign tumour of the soft tissue in the upper extremity” coded with the ICD 10 number D21.1. In the same period, an additional 6 patients were admitted to the authors’ institution with the initial diagnosis of “malignant tumour of the soft tissue in the upper extremity” coded with the ICD 10 number C49.1. All these patients were operated on and the resected tumours examined histologically. The results of histological diagnoses are the basis of this analysis.

Results

The histological types of the resected benign tumours are listed in [Table 3]. The most frequently found were: giant-cell tumours of the tendon sheath – 96 (27.7%), lipomas – 44 (12.7%) and rheumatoid nodules – 30 (8.7%) ([Figs. 1a, b]). Vascular-originated lesions (haemangioma, glomus tumour, vascular malformation, heamangiolipoma and haemangioleyomyoma) were also relatively common, representing 49 cases (14%). Bone tumours (enchondroma and osteochondroma) as well as nerve-originated tumours (schwannoma and neuroma) were fairly common – 27 cases (7.8%) and 10 cases (2.8%) respectively. There were 6 cases of malignant tumours, of these skin cancers were the most common – in 4 patients ([Table 4]) ([Figs. 2] [3] [4]b).

Fig. 2 Epithelioid sarcoma in the palmar side of the hand. Note exophytic growth of the lesion.

Fig. 3 Skin cancer in the distal phalanx of the index finger.

Fig. 4 Chondrosarcoma of the index finger, b. X-ray of the lesion. Note destruction of the bone of the middle phalanx.

Table 3 Histological types of benign tumours in the study.

Histological type of the tumour	No of cases	%
Soft tissue tumours
Giant-cell tumours of the tendon sheath	96	27,7%
Lipoma	44	12,7%
Rheumatiodal nodule	30	8,7%
Fibroma	23	6,6%
Haemangioma	19	5,5%
Glomus tumour	18	5,2%
Enchondroma	17	4,9%
Atheroma (sebaceous cyst)	12	3,5%
Osteochondroma	10	2,9%
Skin granuloma	9	2,6%
Neurofibroma	8	2,3%
Schwannoma	7	2,0%
Dermatokeratosis	6	1,7%
Vascular malformation	5	1,4%
Angiolipoma	5	1,4%
Leiomyoma	4	1,2%
Sebaceous wart	4	1,2%
Neuroma	3	0,9%
Organized thrombus	3	0,9%
Tumoral calcinosis	3	0,9%
Angioleiomyoma	2	0,6%
Fibrolipoma	2	0,6%
Other (single)	16	4,6%
Total	346	100%

Table 4 Histological types of malignant tumours in the study.

Malignant tumours n=6
Skin cancer ([Fig. 3])	4
Chondrosarcoma ([Figs. 4a, b])	1
Epithtelioid sarcoma ([Fig. 2])	1

In 12 cases (3.5%) of initially benign tumours, their clinical presentation and/or intraoperative findings raised suspicions of malignancy, but histological examination did not confirm it. In the remaining 334 cases (96.5%) the resected tumours were routinely given histological examination. By contrast, in all cases of malignant tumours, the clinical presentation clearly suggested malignant character of the lesion, which was confirmed histologically.

The cost of a histological examination of a non-malignant soft tissue tumour in the institutional Department of Pathology is calculated as 26 Euro per one sample. Considering that 2–3 samples (in average) are required for confident histological verification of one tumour, the total cost for 346 patients amounted to 18,000–27,000 Euro. As these samples were examined over 3 years, this gives 6,000–9,000 Euro of annual institutional expenditure.

Discussion

The results of this study show a 100% accordance of the initial (clinical) diagnoses of the tumours with their final histological diagnoses, with regard to their status as benign or malignant. This means that, actually, the histological evaluation of the lesions was justifiable in only 12 cases (3.5%) in which clinical presentation or intraoperative findings raised suspicions of malignancy, but in the remaining cases they might be omitted. By contrast, pathology evaluation of tumours that at first sight look malignant, should be routinely performed due to obvious reasons. The results of this study confirm that routine histological evaluation of all tumours resected from the upper extremity is not necessary, and may be confined to selected cases in which clinical presentation and/or intraoperative findings raise suspicions of malignancy. However, the author is not saying that pathology evaluation should be omitted in most cases of resected lesions. This would be inconsistent with common rules of oncological alertness and might lead to mistakes and problems for both patients and surgeons. The author only says that there is very high consistence between clinical and actual histological diagnoses of the upper extremity tumours. It may prompt surgical societies to change the rules in this field and replace them with less restricted ones.

Several authors have claimed that because malignant tumours of the upper extremity are so rare, their histopathological examination is not beneficial to warrant routine examination [6] [7]. Routine pathologic evaluation of excised specimens has been questioned in many surgical fields including plastic surgery, orthopaedic surgery, urology, otolaryngology and general surgery [4]. Previous works have uniformly found that routine surgical pathology diagnosis did not change the treatment plan and thus concluded the practice neither cost-effective nor cost-beneficial [6] [7] [8]. In the field of hand surgery, the necessity of histological examination of benign tumours such ganglions, lipomas and sebaceous cysts has been investigated in a few case series demonstrating minimal risk of overlooking malignancy and no clinical benefit [5] [8] [9].

Sluijmer et al., presented results of a study investigating correlation between clinical and histopathological examination of 182 benign-looking tumours resected from the upper limb over a 10-year period, excluding ganglion cysts. A preoperative initial diagnosis was applied for 125 tumours (69%). The most common pathological diagnoses were lipomas – 35 cases (19%), giant cell tumours of the tendon sheath – 35 cases (19%) and vascular tumours – 29 cases (16%). One lesion without a preoperative diagnosis was a malignant tumour, but the authors consider this unusual and possibly spurious. They conclude that a hand surgeon’s preoperative diagnosis without imaging is usually correct prior to excision of a mass in the hand. Discrepant diagnoses are usually benign and do not alter treatment [5].

Cho et al. [4], presented results of an analysis of a national level database to form a cohort of adult patients who underwent excision of non-malignant upper extremity tumours. The authors aimed to examine the national utilisation of routine pathology examination of non-malignant hand lesions to help guide healthcare policy and practice patterns. They also calculated the total cost of routine histological evaluation. A total of 182,962 specimens from 153,518 cases were included in the analysis. After sorting data by ICD codes, the ICD 10 – D21.1 – “benign neoplasm of skin of upper limb, including shoulder” was the most prevalent clinical diagnosis, and presented also the highest rate of specimen submission (87%). Ganglion of joint (ICD – M67.4) was the second most prevalent diagnosis, with rate of submission at 70%. Only 879 patients (0.6%) had a malignant diagnosis made within 2 months from the initial excision of the upper extremity lesion. Out of this subgroup, 319 patients (0.2%) underwent a second excision of the tumour within 2 months from the primary surgery. There were 319 discordant cases (0.2%) and 560 discrepant cases (0.4%) in the analysed group. The odds of malignant diagnosis were statistically significant for age groups 55–64 years (OR=1.41) and>65 years (OR=2.37), as well as in patients with higher comorbidity scores (OR=2.20–6.83). These results indicate that a patient’s older age and higher comorbidity score should alert the surgeon to the likelihood of a malignant diagnosis. The mean cost of routine pathology exam was 133 USD per specimen and annual expenditure of 5 million USD. The authors conclude that the routine histological examination of benign hand tumours is utilised frequently while providing limited clinical benefit at a cost. They suggest that surgeons should be more aware of the low value of routine pathology evaluation and be more selective for cases for which diagnostic testing will change management [4].

Routine histological examination of all tissues removed during an operation is associated with significant costs, estimated to 46 billion USD annually in the United States [4]. In 1999, the College of American Pathologists published a set of updated recommendations by including the list of specimen types exempt from routine pathological evaluation: those that “by nature or condition do not permit productive examination,” and those with which “the quality of care has not been compromised by the exception” [4]. This approach resulted in less categorical rules, greater confidence in the surgeon’s experience and the belief that an experienced hand surgeon has the ability and the duty to preselect which specimens should be sent for histological evaluation, to reduce unnecessary costs.

However, it should also be noted that the conclusions from this study refer to the average hand unit. It is obvious that in departments dedicated to dealing with malignant tumours, all resected specimens should be given histological examination. As mentioned earlier, another argument for submission of resected tumours for pathology evaluation is concern of completeness of the excision, however, this only applies to tumours having no well-defined capsule. It is also worth noting that there are some benign types of tumours, which tend to recurrence, i. e. giant cell tumours of the tendon sheath with extension into joints or bone. Sometimes such recurrences are not always so easily to categorize clinically. In such cases, it would be helpful to have a clear histopathological diagnosis from the previous surgery.

In conclusion, the results of this study allow the question contained in the title to be answered. The routine histological evaluation of all tumours resected from the upper extremity is not necessary, and may be confined to selected cases in which clinical presentation and/or intraoperative findings raise suspicions of malignancy.

Conflict of Interest

The authors declare that they have no conflict of interest.

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Publication History

Received: 27 December 2023

Accepted: 13 February 2024

Article published online:
07 May 2024