Introduction



This study documents the first reported case of a rapidly growing (volar) thenar eminence ganglion arising form the first carpometacarpal joint, masquerading as a sarcoma. The discussion informs the hand surgeon on the evidence regarding the unusual presenting features.



Case presentation



An 85 year old left hand dominant female presented with a six week history of rapidly growing lump on the thenar eminence. Clinical examination revealed a non-tender large lobulated mobile swelling measuring 5 × 4 cm and involving the whole thenar eminence.



Conclusion



Ganglia may present from the thenar eminence and are a source of diagnostic confusion

A Mandal

EA Azzopardi

ED Butler

EW Brien

L Carp

M Campanacci

M Kulkarni

PC Leung

S Gujral

English

PubMed

Springer - Publisher Connector

BioMed CentralCases Journal
ssOpen AcceCase Report
Rapidly expanding thenar eminence ganglion: a case report
EA Azzopardi*, S Gujral, A Mandal and M Kulkarni
Address: Specialty Registrar, Department of Plastic Reconstructive and Aesthetic Surgery, Wexham Park Hospital, Slough, UK
Email: EA Azzopardi* - ernest_azzopardi@yahoo.co.uk; S Gujral - sameergujral@yahoo.com; A Mandal - animandal@hotmail.com; 
M Kulkarni - mahendra@hotmail.com
* Corresponding author    
Abstract
Introduction: This study documents the first reported case of a rapidly growing (volar) thenar
eminence ganglion arising form the first carpometacarpal joint, masquerading as a sarcoma. The
discussion informs the hand surgeon on the evidence regarding the unusual presenting features.
Case presentation: An 85 year old left hand dominant female presented with a six week history
of rapidly growing lump on the thenar eminence. Clinical examination revealed a non-tender large
lobulated mobile swelling measuring 5 × 4 cm and involving the whole thenar eminence.
Conclusion: Ganglia may present from the thenar eminence and are a source of diagnostic
confusion.
Introduction
A rapidly expanding (volar) thenar eminence ganglion is
a rare entity that may easily be confused with malignant
soft tissue tumors. To our knowledge this the first reported
case in the literature, both in site of (thenar eminence)
and its unusually rapid expansion (5 × 4 cm in 6 weeks).
Case presentation
An 85 year old left hand dominant female presented with
a six week history of rapidly growing lump on the thenar
eminence. Clinical examination revealed a non-tender
large lobulated mobile swelling measuring 5 × 4 cm and
involving the whole thenar eminence. A sarcoma was ini-
tially suspected. Plain X-ray (figure 1) revealed severe oste-
openia with erosive changes in the first Carpometacarpal
joint, and a soft tissue swelling around an osteophyte
detached from the base of the first metacarpal. MRI
reported a septate thin walled cystic structure extending
from the first carpo-metacarpal joint space against a back-
ground of diffuse active synovitis (figure 2). In operating
theater, a multilobulated lesion with a neck extending to
the first CMC joint was observed. The histological analysis
revealed a 3.4 g previously opened specimen consistent
with a ganglion cyst. The patient made an excellent post-
operative recovery with no evidence of recurrence.
Discussion
In an effort to increase the rigor of our study by reducing
retrieval bias, the structured search is being reported. This
was performed using the search-construct "((Thenar OR
Palmar OR Volar) AND Ganglion)" across the following
databases: Pubmed EMBASE, AMED, CINAHL.
While dorsal and wrist ganglia are common in the upper
limb, our literature search retrieved only one other article
describing a volar wrist ganglion. Our case is materially
different since Chiu and Aschermann reported a slowly
enlarging ganglion arising from the wrist whereas the case
reported here derived from the first carpometacarpal joint,
expanded volarly, and rapid expanded over six weeks to
Published: 6 February 2009
Cases Journal 2009, 2:129 doi:10.1186/1757-1626-2-129
Received: 26 November 2008
Accepted: 6 February 2009
This article is available from: http://www.casesjournal.com/content/2/1/129
© 2009 Azzopardi et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 2
(page number not for citation purposes)
Cases Journal 2009, 2:129 http://www.casesjournal.com/content/2/1/129Publish with BioMed Central   and  every 
scientist can read your work free of charge
"BioMed Central will be the most significant development for 
disseminating the results of biomedical research in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central 
yours — you keep the copyright
Submit your manuscript here:
http://www.biomedcentral.com/info/publishing_adv.asp
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the reported dimensions. Chiu and Aschermann (1993)
reported an 'extensive review of the literature' to claim the
first report of a ganglion presenting as a thenar mass.
However they did not report a reproducible literature e
search strategy to substantiate their claim.
Our patient presented at an atypical 85 years of age, in an
atypical volar position and in an atypical rate of growth.
Such a presentation may lead the unsuspecting clinician
to disregard the possibility of this diagnosis when exam-
ining a thenar eminence lump. Conversely although soft
tissue sarcomas of the hand are uncommon, the most fre-
quent presentation is a painless soft tissue mass in the the-
nar eminence. The clinical confusion with sarcomas may
prevent diagnostic aspiration, due to fears about seeding
the tumor. This distinction between the two pathological
entities is paramount due to the differences between oper-
ative resection, and the distinctly worse prognosis for pal-
mar sarcomas compared to similar lesions elsewhere in an
extremity.
Conclusion
Ganglia may present from the thenar eminence and are a
source of diagnostic confusion. Documentation of an
occurrence of thenar ganglion may alert the hand surgeon
to consider its possibility in planning diagnostic and oper-
ative procedures, and avoid patients' undue anxiety.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AM, and SG contributed towards retrieval of data. EA per-
formed the literature meta-search and was a major con-
tributor in writing the manuscript. MK was essential for
delivering a clinical perspective and critically reviewing
the manuscript.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
References
1. Carp L, Stout AP: A study of ganglion with especial reference
to treatment.  Surg Gynecol Obstetr 1928, 47:460.
2. Butler ED, Hamill JP, Seipel RS, et al.: Tumours of the hand: A ten
year survey and report of 437 cases.  Am J Surg 1960, 100:293.
3. Leung PC: Tumors of the hand Hand 1960, 13:169.
4. Brien EW, Terek RM, Geer RJ, Caldwell G, Brennan MF, Healey JH:
Treatment of soft-tissue sarcomas of the hand.  J Bone Joint Surg
Am 1995, 77:564-571.
5. Campanacci M, Bertoni F, Laus M: Soft tissue sarcoma of the
hand.  Italian I Orthop and Traumatol 1981, 7:313-327.
Plain x-ray appearance of the degenerative changes in the first carpometacarpal joinFigure 1
Plain x-ray appearance of the degenerative changes 
in the first carpometacarpal joint.
MRI appearance of thenar eminence ganglionFigure 2
MRI appearance of thenar eminence ganglion.Page 2 of 2
(page number not for citation purposes)


Rapidly expanding thenar eminence ganglion: a case report

Crossref

Azzopardi, Ernest A.

Gujral, S.

Mandal, A.

Kulkarni, M.

Online Research @ Cardiff

BioMed CentralCases JournalssOpen AcceCase ReportRapidly expanding thenar eminence ganglion: a case reportEA Azzopardi*, S Gujral, A Mandal and M KulkarniAddress: Specialty Registrar, Department of Plastic Reconstructive and Aesthetic Surgery, Wexham Park Hospital, Slough, UKEmail: EA Azzopardi* - ernest_azzopardi@yahoo.co.uk; S Gujral - sameergujral@yahoo.com; A Mandal - animandal@hotmail.com; M Kulkarni - mahendra@hotmail.com* Corresponding author    AbstractIntroduction: This study documents the first reported case of a rapidly growing (volar) thenareminence ganglion arising form the first carpometacarpal joint, masquerading as a sarcoma. Thediscussion informs the hand surgeon on the evidence regarding the unusual presenting features.Case presentation: An 85 year old left hand dominant female presented with a six week historyof rapidly growing lump on the thenar eminence. Clinical examination revealed a non-tender largelobulated mobile swelling measuring 5 × 4 cm and involving the whole thenar eminence.Conclusion: Ganglia may present from the thenar eminence and are a source of diagnosticconfusion.IntroductionA rapidly expanding (volar) thenar eminence ganglion isa rare entity that may easily be confused with malignantsoft tissue tumors. To our knowledge this the first reportedcase in the literature, both in site of (thenar eminence)and its unusually rapid expansion (5 × 4 cm in 6 weeks).Case presentationAn 85 year old left hand dominant female presented witha six week history of rapidly growing lump on the thenareminence. Clinical examination revealed a non-tenderlarge lobulated mobile swelling measuring 5 × 4 cm andinvolving the whole thenar eminence. A sarcoma was ini-tially suspected. Plain X-ray (figure 1) revealed severe oste-openia with erosive changes in the first Carpometacarpaljoint, and a soft tissue swelling around an osteophytedetached from the base of the first metacarpal. MRIreported a septate thin walled cystic structure extendingfrom the first carpo-metacarpal joint space against a back-ground of diffuse active synovitis (figure 2). In operatingtheater, a multilobulated lesion with a neck extending tothe first CMC joint was observed. The histological analysisrevealed a 3.4 g previously opened specimen consistentwith a ganglion cyst. The patient made an excellent post-operative recovery with no evidence of recurrence.DiscussionIn an effort to increase the rigor of our study by reducingretrieval bias, the structured search is being reported. Thiswas performed using the search-construct "((Thenar ORPalmar OR Volar) AND Ganglion)" across the followingdatabases: Pubmed EMBASE, AMED, CINAHL.While dorsal and wrist ganglia are common in the upperlimb, our literature search retrieved only one other articledescribing a volar wrist ganglion. Our case is materiallydifferent since Chiu and Aschermann reported a slowlyenlarging ganglion arising from the wrist whereas the casereported here derived from the first carpometacarpal joint,expanded volarly, and rapid expanded over six weeks toPublished: 6 February 2009Cases Journal 2009, 2:129 doi:10.1186/1757-1626-2-129Received: 26 November 2008Accepted: 6 February 2009This article is available from: http://www.casesjournal.com/content/2/1/129© 2009 Azzopardi et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 2(page number not for citation purposes)Cases Journal 2009, 2:129 http://www.casesjournal.com/content/2/1/129Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralthe reported dimensions. Chiu and Aschermann (1993)reported an 'extensive review of the literature' to claim thefirst report of a ganglion presenting as a thenar mass.However they did not report a reproducible literature esearch strategy to substantiate their claim.Our patient presented at an atypical 85 years of age, in anatypical volar position and in an atypical rate of growth.Such a presentation may lead the unsuspecting clinicianto disregard the possibility of this diagnosis when exam-ining a thenar eminence lump. Conversely although softtissue sarcomas of the hand are uncommon, the most fre-quent presentation is a painless soft tissue mass in the the-nar eminence. The clinical confusion with sarcomas mayprevent diagnostic aspiration, due to fears about seedingthe tumor. This distinction between the two pathologicalentities is paramount due to the differences between oper-ative resection, and the distinctly worse prognosis for pal-mar sarcomas compared to similar lesions elsewhere in anextremity.ConclusionGanglia may present from the thenar eminence and are asource of diagnostic confusion. Documentation of anoccurrence of thenar ganglion may alert the hand surgeonto consider its possibility in planning diagnostic and oper-ative procedures, and avoid patients' undue anxiety.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsAM, and SG contributed towards retrieval of data. EA per-formed the literature meta-search and was a major con-tributor in writing the manuscript. MK was essential fordelivering a clinical perspective and critically reviewingthe manuscript.ConsentWritten informed consent was obtained from the patientfor publication of this case report and accompanyingimages. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.References1. Carp L, Stout AP: A study of ganglion with especial referenceto treatment.  Surg Gynecol Obstetr 1928, 47:460.2. Butler ED, Hamill JP, Seipel RS, et al.: Tumours of the hand: A tenyear survey and report of 437 cases.  Am J Surg 1960, 100:293.3. Leung PC: Tumors of the hand Hand 1960, 13:169.4. Brien EW, Terek RM, Geer RJ, Caldwell G, Brennan MF, Healey JH:Treatment of soft-tissue sarcomas of the hand.  J Bone Joint SurgAm 1995, 77:564-571.5. Campanacci M, Bertoni F, Laus M: Soft tissue sarcoma of thehand.  Italian I Orthop and Traumatol 1981, 7:313-327.Plain x-ray appearance of the degenerative changes in the first carpometacarpal joinFigure 1Plain x-ray appearance of the degenerative changes in the first carpometacarpal joint.MRI appearance of thenar eminence ganglionFigure 2MRI appearance of thenar eminence ganglion.Page 2 of 2(page number not for citation purposes)

Rapidly expanding thenar eminence ganglion: A case report

Ernest Azzopardi

Cronfa at Swansea University

AP: A study of ganglion with especial reference to treatment. Surg Gynecol Obstetr

Rapidly expanding thenar eminence ganglion: a case report

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