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Ganglia and myxoid (mucous) cysts are common presentations. Observation and primary care assessment and management are appropriate for the majority of cases. Complications are rare and settle without the need for further intervention.
In one study comparing patients who had undergone surgery and patients whose ganglion was left untreated, no difference in symptoms was reported in the long term. Complication rates vary according to the type of surgery and are reported to range from 5% to 10% of procedures.
There is a Surgery for ganglion cyst commissioning policy that accompanies this Clinical Referral Guideline. Please note pre-referral criteria are applicable and referrals may be returned if this information is not contained within the referral letter.
Diagnostic uncertainty with no suspicion of malignancy is not an indication for referral under these guidelines. A watchful waiting approach can often be helpful if there is uncertainty. In cases of diagnostic uncertainty where malignancy needs to be excluded, please consider whether imaging or a 2ww referral might be indicated
Although they commonly occur as benign lesions in adults, ganglia are much less common in children therefore symptomatic soft tissue masses in children fall out of the scope of these guidelines.
Ganglia of the hand and wrist are common benign lesions. Ganglia less commonly present at the foot and ankle. They most frequently arise adjacent to joints and tendons, but may also be intratendinous or intraosseous.
Digital myxoid or mucoid cysts typically occur at the distal interphalangeal joints and can be associated with osteoarthritic joints. They can intermittently become inflamed but are rarely truly infected.
Both ganglia and myxoid cysts may be cosmetically noticeable (the latter can also cause disruption of nail growth). They can sometimes be painful or cause limitation of function.
Referrers should be aware that certain pathology do not turn out to be ganglia but can present in a similar way. The following conditions fall into this category:
The majority of these lesions do not require onward referral and can be observed in primary care.
The majority of ganglia occur in the upper limbs. For lower limbs in particular, diagnostic uncertainty should prompt consideration of further imaging.
Soft tissue sarcomas are rare and account for approximately 1% of all malignant tumours. The age standardised incidence rate for soft tissue sarcoma for England is 44.9 cases per 1million population. This equates to 53 new cases per year in Devon.
If aspiration of the lesion has not been possible (usually ganglia exude a thick clear gel when aspirated with a wide gauge needle under local anaesthetic) this should prompt the possibility of the lesion being a solid tumour.
The 2ww criteria for referral to the liposarcoma service include any of the following:
In primary care, ultrasonography can be useful to evaluate superficial lumps of diagnostic uncertainty especially if examination findings are equivocal. The National Institute for Health and Care Excellence (NICE) recommends urgent ultrasonography for all unexplained lumps increasing in size.
Aspiration of a thick clear gel from a suspected ganglion can help confirm diagnosis.
Most ganglia can be managed in primary care. Patients can be reassured that approximately 60% of ganglia resolve spontaneously therefore a simple watch and wait approach is often appropriate.
Ganglia frequently recur, but this is also true following surgical treatments.
For ganglia of the wrist and hand, the cure rate following aspiration increases with 3 week splinting post procedure.
*Steroid injections work best for preventing recurrence in volar retinacular (flexor tendon sheath) ganglia when combined with transverse massage, but should be avoided for volar radial ganglia due to the proximity of the radial artery.
Surgery for removal of a ganglion cyst will be routinely commissioned only in the following circumstances. Referrals may be returned if the referral letter does not provide sufficient information to demonstrate the following criteria are met.
*Significant functional impairment is defined as a loss or absence of an individual's capacity to meet personal, social or occupational demands.
There is an expectation that the patient should have tried at least 6 months of conservative measures including:
the patient should have been made aware that ganglia often resolve spontaneously and of the potential complications of ganglia surgery (complication rates vary according to the type of surgery and are reported to range from 5% to 10% of procedures.)
Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally
This guideline has been signed off on behalf of NEW Devon CCG by the Planned Care Control Centre.
Publication date: May 2017