DR, an 38-year-old male presented with a 1-cm mass on the ventral (or volar) side of her left hand near the base of the thumb. The mass was underneath the skin and firm and felt cystic.
Based on pattern recognition and prevalence, the primary diagnosis is a ganglion cyst and the secondary diagnosis (based on the cystic characteristic), an inclusion cyst. The choice of ganglion cyst as the primary diagnosis is based primarily on prevalence and this is the most common type of non-malignant mass in the wrist area.
If there is a question on whether the mass is cystic or solid, then the set of primary and secondary clinical diagnoses will change. The primary clinical diagnosis will still be ganglion cyst as there is a possibility that it is cystic and it is the most common type of non-malignant lesion in the wrist area. The secondary clinical diagnosis will be (considering that it may be solid) is a giant cell tumor.
If the mass feels solid and firm, then another set of primary and secondary clinical diagnosis is formulated. The primary clinical diagnosis will be giant cell tumor primarily based on prevalence (most common solid non-malignant tumor in the wrist area) and secondary clinical diagnosis will be fibroma.
Thus, one sees the primary and secondary clinical diagnoses will be dependent on the signs (and symptoms) present in the patient and they are decided through the processes called pattern recognition (or pattern matching) and prevalence.
Suppose the primary clinical diagnosis is a ganglion cyst with a 98% degree of certainty. With such a degree of certainty, one does not need a paraclinical diagnostic procedure anymore. Ganglion cyst becomes the pretreatment diagnosis.
Next step is to spell out the goal of treatment, which is resolution of the mass, the ganglion cyst. There are usually more than one option in the treatment of ganglion cyst. One lists down the various options and then compare them using benefit-risk-cost-availability factors.
Options include needle aspiration, excision, and injection of substances.
Comparison on benefit (resolution – incidence of recurrence)
- Observation – 58% spontaneously resolved.
- Needle aspiration – 87% recurrence rate; 15% after 3 aspirations
- Needle aspiration with injection of steroid -67% recurrence rate
- Excision -dorsal ganglia: 3% to 9% recurrence rate; volar ganglia: 7% to 19% recurrence rate
Comparison of risk (complications, discomfort, etc.
- Observation – grow bigger
- Needle aspiration – pain on needle aspiration
- Needle aspiration with injection of steriod -pain on needle aspiration and injection of steroid
- Excision – wound infection, neuroma formation, hypertrophic scar, median nerve, radial artery damage, with complication rate ranging 0–56%
- Needle aspiration – lowest expense
- Needle aspiration with injection of steriod – higher expense
- Excision – highest expense
Availability (readily available and accessible)
- Needle aspiration – readily available (syringe and hypodermic needle – clinic procedure)
- Needle aspiration with injection of steroid – not as readily available and accessible (steroid)
- Excision – not as readily accessible as this is usually done in the operating room
Recommendations: (Health-Process-Evidence-based Clinical Practice Guidelines on Treatment of Ganglion Cysts of Wrist)
- Option for observation, if ganglion cyst is small (about 1 cm), and patient refuses active treatment. Spontaneous resolution in 58% of cases.
- Needle aspiration – initial active treatment, may be repeated if with recurrence.
- Needle aspiration with injection of substance – if with persistent recurrence, say 3 or more.
- Excision – if with persistent recurrence despite needle aspiration or if with persistent recurrence despite needle aspiration with injection of substance
If the above management of patient process is followed, the patient will have at least a rational process of management. With rational management, value-based services are provided.
This patient was given a diagnosis of ganglion cyst by an orthopedic surgeon, who then advised magnetic resonance imaging (MRI) prior to surgical excision.
The patient came to me for second opinion. My primary clinical diagnosis was ganglion cyst. I did a needle aspiration and I obtained colorless gel accompanied by complete disappearance of mass. This confirmed the pretreatment diagnosis of ganglion cyst. The mass recurred 9 months after. I repeated the needle aspiration. Plan of treatment: continue to monitor (for remission and recurrence).
Clinical diagnosis + needle aspiration = PhPx,000 = disappearance of ganglion cyst
Clinical diagnosis + MRI + surgical excision = 10 times PhPx,000 (may have same disappearance of ganglion cyst but with pain, scar, and other potential postoperative complication)