Ganglia and Myxoid Cysts

Scope

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

Out of scope

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.

​Assessment

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.

Differential Diagnoses

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:

  • Osteoarthritic changes in a joint
  • Gouty tophi, rheumatoid nodules or synovitis
  • Giant cell tumours
  • Lipomas and other benign lesions
  • Plantar fibromas
  • Malignancy (rare): see Red Flag section for more information regarding 2ww criteria

The majority of these lesions do not require onward referral and can be observed in primary care.

Red Flags

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.

Signs and symptoms:

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:

  • Measurement exceeds 4cm
  • Significant persistent pain that is not solely pressure related
  • Rapid growth over a short period of time
  • Deep fixity to muscle or fascia (the mass becomes less obvious on muscle contraction)
  • Prior malignancy other than basal cell carcinoma

Investigations

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.

Management

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.

  • Options for primary care management include:
  • Simple splint immobilization for upper limb ganglia
  • Analgesia
  • Aspiration or lancing with sterile wide gauge needle under local anaesthetic – may need repeated treatments.
  • Steroid injections *

Ganglia frequently recur, but this is also true following surgical treatments.

Notes:

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.

Referral

Referral Criteria

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.

  • Ganglion of the upper or lower limb causing significant pain or significant functional impairment*
  • Mucoid (myxoid) cysts at distal interphalangeal joint (DIP) which is causing significant functional impairment* or pain, or there are cysts that discharge

*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:

  • short courses of simple analgesia for episodes of pain
  • reasonable occupational and lifestyle adjustments to reduce functional impact of the ganglion

AND

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

Individual funding requests

Referral Forms

Ganglion Cyst Interventions Referral Proforma EMIS web

Ganglion Cyst Interventions Referral Proforma Microtest

Ganglion Cyst Interventions Referral Proforma No Merge Fields

Ganglion Cyst Interventions Referral Proforma Systmone

Supporting Information

Patient Information

MyHealth patient information - Ganglion cyst

Evidence

References

Pathway Group

This guideline has been signed off on behalf of NEW Devon CCG by the Planned Care Control Centre.

Publication date: May 2017

 

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