Magnetic Resonance Imaging in the Diagnosis of Glomus Tumours of the Hand

Glomus Tumors: A Review of Preoperative Magnetic Resonance Imaging to Detect Satellite Lesions

Glomus tumors are malformations of the neuromyoarterial system that commonly develop in the digits and cause exquisite tenderness, especially with cold temperatures. Treatment typically involves surgical excision, although there is a tendency to avoid aggressive resections, which may lead to aesthetically displeasing nail plate deformities. In a minority of patients, symptoms may persist and the tumor may recur. The etiology of the persistent of symptoms is debatable. One theory for the persistence of symptoms is an incomplete initial excision of the glomus tumor. Another theory suggests that clinically unapparent satellite lesions exist at the time of diagnosis that are not excised, and they later mature into symptomatic recurrent tumors. Although not clinically visible, if present, these satellite lesions should be seen on preoperative magnetic resonance imaging. The authors reviewed all cases of pathology-confirmed glomus tumors in the past 7 years at a single institution in which preoperative magnetic resonance imaging using a high-powered 3.0 Tesla (General Electric, Buckinghamshire, United Kingdom) magnet was performed. Six cases met inclusion criteria and only 1 case developed a recurrent glomus tumor. None of the cases were found to have satellite lesions associated with the primary glomus tumor on magnetic resonance imaging. Preventing recurrence seems to be dependent on the completeness of the initial excision. Preoperative magnetic resonance imaging is a valuable tool used to delineate the extent of the tumor for surgical planning.

Nail-preserving modified lateral subperiosteal approach for subungual glomus tumour: a novel surgical approach

PURPOSE

Glomus tumours are benign, vascular neoplasms arising from glomus body and are often found near the fingertips. Complete surgical excision of the tumour must be ensured to avoid its recurrence. Several surgical approaches for its excision have been described in the literature; however, most of the approaches are associated with nail deformity in the post-operative period or fail to offer a complete exposure of the tumour. We wish to share our experience with our described nail-preserving modified lateral subperiosteal approach, where on account of the distal curve over the pulp tip, we achieve a large flap yielding an excellent exposure of the tumour mass.

METHODS

We retrospectively evaluated 30 patients with subungual glomus tumour who were operated using this approach at a mean follow-up of 35.33 months. All patients were assessed for relief in the pre-operative symptoms, nail deformity, recurrence or any other complications.

RESULTS

All wounds healed well without any possible wound complications such as wound dehiscence, suture margin necrosis or infection. At the end of the follow-up, all patients were relieved of the pre-operative symptoms. There was no evidence of deformity of nail or fingertip. No patient had recurrence. All the operated fingers were functionally normal.

CONCLUSIONS

Nail-preserving modified lateral subperiosteal approach does not damage the nail bed or interosseous supports to the distal phalanx. It is a very simple, less time-consuming approach for the resection of subungual tumours, and we would like to recommend it to our fellow orthopaedic surgeons.

Multiple glomus tumors presenting as an aesthetic abnormality

Glomus tumors are benign soft-tissue neoplasms. Commonly found in the digits, glomus tumors can rarely arise in extradigital locations and may result in misdiagnosis or delay in diagnosis. Plastic surgeons should therefore include glomus tumors in the differential diagnosis of patients who present with painful, red- or blue-colored extradigital lesions. The authors present a rare case of extradigital glomangioma tumors of the right and left thigh in a 35-year-old woman. This case report describes an atypical presentation of multiple glomus tumors and reviews diagnostic and treatment modalities.

LEVEL OF EVIDENCE V

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Characteristics of glomus tumors in the hand not diagnosed on magnetic resonance imaging

PURPOSE

To determine whether the diagnosis of hand glomus tumors by magnetic resonance imaging (MRI) is associated with tumor size, tumor pathology, tumor location, and/or clinical suspicion.

METHODS

We reviewed our pathology database for patients with hand glomus tumors diagnosed between 2006 and 2013 and included those patients who had preoperative MRI at our institution. We excluded patients with recurrent and persistent tumors. Magnetic resonance imaging reports were reviewed for clinical history, tumor location, and associated bone erosion. Pathology reports were reviewed for diagnosis and tumor size. We classified MRI studies as positive (glomus tumor diagnosis), negative (no mention of glomus tumor as possible diagnosis), or indeterminate (glomus tumor mentioned as possible differential diagnosis). Fisher exact test was used to compare positive studies and those that were nondiagnostic (ie, either negative or indeterminate).

RESULTS

Of the 46 patients who had pathologically confirmed hand glomus tumors, 38 had preoperative MRI studies. A total of 24 MRI studies were positive, 5 were indeterminate, and 7 were negative. Five patients had atypical pathology, 1 had a multifocal tumor, and 2 had extra-digital hand glomus tumors. Failure to diagnose glomus tumors on MRI was associated with atypical pathology, atypical location (ie, not located in the subungual region), absence of bone erosion, and lack of clinical suspicion. Tumor size was not associated with MRI diagnosis.

CONCLUSIONS

In this series of 36 hand glomus tumors, one-third of MRI studies were nondiagnostic. Occurrence of nondiagnostic MRIs was more likely when glomus tumors were pathologically and/or anatomically atypical, without bone erosion, and with no or unrelated clinical history provided. These findings highlight the continued importance of clinical suspicion in glomus tumor diagnosis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Accuracy of MRI-based Diagnoses for Distal Upper Extremity Soft Tissue Masses

To determine the accuracy of the pre-operative MRI-based diagnosis of soft tissue masses in the forearm, wrist, and hand, the records of 144 patients who underwent an MRI followed by excision of a soft tissue mass in the forearm, wrist, or hand were reviewed. The MRI-based diagnosis was compared to the histological diagnosis, which was considered the gold standard. The sensitivity, specificity, positive predictive value, and negative predictive value of the MRI-based diagnosis were calculated. A multivariate regression analysis was performed.While the accuracy of the MRI-based diagnosis varied widely, there was an overall sensitivity of 75 %. The most accurate diagnosis was an MRI-based diagnosis of ganglion cyst, which had a sensitivity of 94.7 % and a specificity of 94.4 %. Of particular concern was that the MRI-based diagnosis of a malignancy was only 66.7 % sensitive, with a positive predictive value of 44.4 %. On multivariate regression analysis, there was a trend towards improved accuracy in the wrist when compared to the finger, although this did not reach statistical significance.While pre-operative MRI remains a valuable tool for the evaluation of soft tissue masses in the distal upper extremity, caution is warranted when basing the diagnosis on MRI evidence alone.

LEVEL OF EVIDENCE

Level IV/Diagnostic.

Subungual glomus tumors of the hand: Treated by transungual excision

BACKGROUND

Glomus tumors are benign hamartomas arising from the glomus body, mostly occurring in the subungual region of the digits. A triad of excruciating pain, localized tenderness and cold sensitivity is the key to diagnosing these tumors. Two surgical approaches are described in the literature for excision of subungual glomus tumors-transungual and periungual. We reviewed retrospectively the results of subungual glomus tumors of the hand treated by transungual excision.

MATERIALS AND METHODS

Twelve patients (9 females and 3 males) with histopathologically confirmed subungual glomus tumors of the hand were treated by transungual excision at our institute. The mean age of the patients was 40.5 years (range 28-63 years). All patients presented with pain in the nail bed and cold sensitivity. A bluish-brown discoloration was present in 6 patients. Love's pin test was positive in all and Hildreth's test was positive in 8 patients. The mean duration of followup was 38 months (range 8-72 months).

RESULTS

All patients had complete pain relief. There was no new nail deformity and no recurrence till last followup. One patient had deformity of the nail preoperatively due to previous surgery, which persisted after excision of the tumor. All of them returned to their preoperative occupation and regained full function of the hand.

CONCLUSIONS

The transungual approach provides good access to the entire lesion and facilitates complete excision. Contrary to reported literature, we did not find the development of any new nail deformity with this approach.

Glomus tumour of the elbow: a case of mistaken identity

Glomus tumours are small vascular tumours that are usually benign and rarely occur. However, atypical locations of these tumours can lead to misdiagnosis, particularly where the lesion is rarely reported. We report a case of glomus tumour located on the posterior aspect of the elbow, which was mistaken for, and treated as the commonly diagnosed, olecranon bursitis for several years. With worsening symptoms, mainly pain, pinpoint tenderness and hypersensitivity, the patient was referred for a further opinion, and the lesion was diagnosed as a glomus tumour following complete excision under anaesthesia. This present case highlights the importance in considering this rare entity in the differential diagnosis of posterior elbow swelling and pain. Furthermore, this report provides a review of the literature and identifies the need for early specialist referral to confirm diagnosis, alleviate patient symptoms and improve function.

Transungual surgical excision of subungual glomus tumour

Background:

Glomus tumours are rare vascular tumours arising subungually in fingernails. Surgical excision provides histopathologic diagnosis and rapid resolution of symptoms.

Objective:

Present study was aimed at delineating common presentations and long-term treatment outcome of this rare subungual tumour. Patients and Methods: The clinical features and imaging results for 10 patients with subungual glomus tumours were recorded. All were treated with transungual excision. Per-operative findings and, treatment outcomes were recorded and analysed.

Results:

Females outnumbered males with average age being 33.3 ± 7.55 years. Presenting symptoms were severe pain (100%); nail-plate discoloration and onycholysis. X-ray was normal in 70%, though a magnetic resonance imaging done for five, helped visualise the lesion in three patients. The tumour involved nail bed in five cases and matrix in five, with an average size being 6.1 ± 2.13 mm (range 3-11 mm). An average follow-up of 16.8 months (range 8-24 months) was largely uneventful with longitudinal ridging in two cases and recurrence in two (both attributed to a sister lesion).

Conclusion:

Subungual glomus tumours have characteristic clinical presentation. Imaging is helpful pre-operatively but has a low success rate. Transungual surgical excision is safe and effective, allowing better visualisation, easy exploration and minimal long-term complications.

A Glomus Tumour of the Elbow: A Case Report and Review of the Literature

Extradigital glomus tumours are relatively uncommon. We present a case report of a glomus tumour of the elbow and review of the literature with regards to the clinical features, work-up and management of these tumours, to highlight the importance of considering a glomus tumour as part of the differential diagnosis in patient with atypical pain around the elbow.

Large plaque-like glomangioma in a patient with multiple glomus tumours: review of imaging and histology

Glomus tumours are benign tumours of the temperature-sensitive neuromyoarterial glomus body, present within the dermis, which are most commonly seen as solitary subungual lesions on the arms. Multiple glomus tumours or glomangiomas are a less common subtype of extradigital glomus tumours, which very rarely present as large plaque-like dermal lesions. Glomangiomas do not often show the classic triad of symptoms associated with glomus tumours, namely: pain, point tenderness on compression, and temperature sensitivity. As a result of this and of their atypical morphology, they can often be misdiagnosed as vascular malformations (VMs), resulting in delayed diagnosis and inappropriate treatment. We report a 29-year-old man with multiple extradigital glomus tumours that had been present since childhood, with the lesion on the patient's leg being the largest plaque-like glomangioma yet reported, to our knowledge. Spectral greyscale and Doppler shift ultrasonography showed multiple, tubulonodular, ectatic, noncompressible, vascular structures with aberrant flow within the thickened dermis. Using magnetic resonance imaging, low to intermediate signal was seen on T1-weighted images and high signal on T2-weighted images, and there was florid enhancement with gadolinium, with no evidence of extension into muscle or bone. Histology showed abnormal, dilated, thin-walled, vascular channels lined with multiple layers of glomus cells, confirming the diagnosis of a glomangioma. We discuss imaging techniques for plaque-like glomangiomas, and review the clinical, radiological and histological characteristics that help differentiate them from other superficial VMs.

Where is the Lesion? Glomus Tumours of the Hand

Glomus tumours are vascular hamartomas that are commonly found in the hand, particularly the subungual region. They appear as solitary or multiple tumours, and often present as a bluish discoloration of the nail plate. Different diagnostic tests are outlined, as well as imaging studies such as magnetic resonance imaging and ultrasound. Misdiagnosis and delayed diagnosis of these tumours are common, while a familial tendency is a potential risk factor but not yet proven. Complete surgical excision often results in complete symptomatic relief, while recurrences are largely due to incomplete excision or the growth of a new glomus tumour. This article aims to review the key aspects of glomus tumours and provide a diagnostic algorithm so that the lesion can be recognized and treated earlier.

Glomus tumors: symptom variations and magnetic resonance imaging for diagnosis

Background

The typical clinical symptoms of glomus tumors are pain, tenderness, and sensitivity to temperature change, and the presence of these clinical findings is helpful in diagnosis. However, the tumors often pose diagnostic difficulty because of variations in presentation and the nonspecific symptoms of glomus tumors. To the best of our knowledge, few studies have reported on the usefulness of magnetic resonance imaging (MRI) in diagnosing glomus tumors in patients with unspecific symptoms.

Methods

The inclusion criteria of this study were: having undergone surgery for subungual glomus tumor of the hand, histopathologic confirmation of glomus tumor, and having undergone preoperative MRI. Twenty-one patients were enrolled. The characteristics of the tumors and the presenting symptoms including pain, tenderness, and sensitivity to temperature change were retrospectively reviewed.

Results

Five out of 21 patients (23%) did not show the typical glomus tumor symptom triad because they did not complain of pain provoked by coldness. Nevertheless, preoperative MRI showed well-defined small soft-tissue lesions on T1- and T2-weighted images, which are typical findings of glomus tumors. The tumors were completely resected and confirmed as glomus tumor histopathologically.

Conclusions

Early occult lesions of glomus tumor in the hand may not be revealed by physical examination because of their barely detectable symptoms. Moreover, subungual lesions may be particularly difficult to evaluate on physical examination. Our cases showed that MRI offers excellent diagnostic information in clinically undiagnosed or misdiagnosed patients. Preoperative MRI can accurately define the character and extent of glomus tumor, even though it is impalpable and invisible.

Glomus tumor of the cheek: a case report

Glomus tumors are benign, subcutaneous neoplasms of the perivasculature. Though facial location is rare, the diagnosis of a glomus tumor should be considered in cases of undiagnosed painful facial nodules or chronic facial pain. Imaging aids in defining the tumor and planning a complete excision in order to avoid recurrence. Histological examination is mandatory after every attempted excision. A case of glomus tumor of the cheek along with the possible pitfalls of diagnosis and treatment and a brief review of the limited associated literature are presented.

Imaging features of glomus tumors

OBJECTIVE

To describe the imaging findings with pathologic correlation and clinical presentation of glomus tumors.

MATERIALS AND METHODS

We retrospectively searched the surgical pathology database from January 1, 1997, to April 30, 2010, for cases of pathologically proven glomus tumor. Patients who had imaging results available for review were included in the study.

RESULTS

Glomus tumors presented with a prolonged history of focal and often debilitating pain, with a mean duration of symptoms of 7.2 years. Mean tumor size was 13 mm. The upper extremity was involved in 12/25 (48%) of the tumors, the lower extremity in 12/25 (48%), and one case (4%) was within the trachea. Lesions appeared well circumscribed on ultrasonography, with marked vascularity on color Doppler evaluation. Magnetic resonance imaging (MRI) with a marker placed in the region of point tenderness was the best method for identifying small glomus tumors. These tumors had a high T2 signal and uniform enhancement after gadolinium administration.

CONCLUSIONS

The diagnosis of glomus tumor is suggested by imaging features of a small circumscribed mass at the site of point tenderness that show marked vascularity on Doppler evaluation or diffuse contrast medium enhancement on MRI, or both. Early tumor recognition allows surgical resection that completely resolves the crippling, chronic pain of these lesions.

Glomuvenous malformations in the buccal area

Glomuvenous malformations (GVMs) are relatively rare lesions in the head and neck area. A 30-year-old woman presented to our clinic with a large mass on the right buccal area with tenderness and hypersensitivity to palpation. The lesion was excised totally under general anesthesia. Microscopic evaluation and immunostaining method confirmed the diagnosis of GVM. We concluded that a solitary form of GVMs as a large mass on the buccal region could occur, and a mass with tenderness and hypersensitivity on palpation could be significant in its differential diagnosis.

Glomus tumour of fingertip: report of eight cases and literature review

Glomus tumour is a rare, benign, soft-tissue tumour. Eight patients with eight histologically confirmed glomus tumours have been operated within the past 10 years. The median age at the time of diagnosis was 40 years. The tumour was located in the fingertip in all cases. The evolution ranged from 1 to 7 years. Clinically, the paroxysmal pain was usually characterised. Imaging findings were helpful in diagnosis. In post-operative, there was an immediate pain relief. No recurrence was observed during the last follow-up period of 4 years and 10 months.

Benign bony and soft tissue tumors of the hand

It is important to be familiar with the wide variety of benign tumors that may present in everyday hand surgery practice. The treatment of many of these tumors in the hand is based on studies with small numbers of patients or the treatment of similar lesions elsewhere in the body. The purpose of this review is to summarize the recent literature relevant to benign bony and soft tissue tumors in the hand.

Diagnosis of glomus tumor by nail bed and matrix dermoscopy

Surgery is the best treatment for glomus tumors. Sometimes this can be a challenging procedure because, despite being a well-defined tumor, its visualization can be difficult. The use of nail bed and matrix dermoscopy facilitates the diagnosis and aids in the localization and demarcation of the tumor. It is a simple and low-cost procedure that does not involve additional risks to the patient who will undergo surgery.

[Glomus tumors in the extremities of children--a rare cause of chronic pain. Two clinical cases]

Glomus tumor (GT) of limb extremities (finger, toe) is a rare tumor, especially in children. It is formed by hyperplasia of the neuro-myoarterial elements. Chronic pain is often associated. The diagnosis is made by the history and several clinical tests (Hildreth's and Love's tests). This diagnosis must be suspected in a child with chronic extremity pain. Magnetic resonance imaging (MRI) is the most sensitive imaging test. Complete surgical excision of the lesion is curative. We report two clinical cases of glomus tumor of limb extremities (finger and toe) in two children - aged 7 and 12 - causing severe chronic pain; the diagnosis of this condition remains a challenge.

Longitudinal erythronychia: suggestions for evaluation and management

Longitudinal erythronychia is a frequent nail presentation with a limited differential diagnosis. This clinical entity may be divided into cases that involve one (localized) or multiple (polydactylous) nails. The different presentations have distinct differential diagnoses and workups yet often share a common pathogenesis. Localized longitudinal erythronychia most commonly represents onychopapilloma, yet malignancies may present identically. Therefore biopsy may be required. Polydactylous longitudinal erythronychia usually coincides with a regional or systemic cause. Occasionally, it may herald an important underlying disease. A thorough understanding of the pathogenesis, clinical presentations, and possible diagnoses is necessary for successful evaluation and management.

Diagnosis, management, and complications of glomus tumours of the digits in neurofibromatosis type 1

BACKGROUND

Glomus tumours are benign painful tumours of the glomus body, a thermoregulatory shunt in the digits. Glomus tumours of the fingers and toes are associated with the monogenic disorder neurofibromatosis type 1 (NF1) and are recently recognised as part of the NF1 phenotype.

METHODS AND RESULTS

A multi-institutional experience with 15 individuals with NF1 and glomus tumours of the fingers or toes is reported. The majority of individuals presented with at least two of the symptoms in the classic triad of localised tenderness, severe paroxysmal pain, and sensitivity to cold. Appearance of the nail and finger or toe is often normal. Women are affected more often than men. Multifocal tumours are common. There is often a delay in diagnosis of many years and clinical suspicion is key to diagnosis, although magnetic resonance imaging may be useful in some scenarios. Surgical extirpation can be curative; however, local tumour recurrence and metachronous tumours are common. Three of our patients developed signs and symptoms of the complex regional pain syndrome.

CONCLUSIONS

Glomus tumours in NF1 are more common than previously recognised and NF1 patients should be specifically queried about fingertip or toe pain.

Glomus tumor of the kidney

A 41-year-old man was diagnosed with a glomus tumor of the kidney, which was incidentally found by ultrasonography. Partial nephrectomy revealed a 10-mm encapsulated mass. We diagnosed it as a glomus tumor using morphological and immunohistochemical stains.

Benign tumors and pseudotumors of the nail: a novel application of sonography

OBJECTIVE

The purpose of this study was to determine the scope of high-resolution sonography in the detection of benign tumors and pseudotumors of the nail unit.

METHODS

We performed a retrospective study of the sonographic findings in 103 consecutive patients with benign tumors and pseudotumors of the nail that were medically derived and confirmed histologically. Statistical analysis (Student t test) was performed comparing clinical and sonographic diagnoses.

RESULTS

Common benign tumors and pseudotumors of the nail can be detected on sonography, and they present different sonographic morphologic characteristics. According to origin, the lesions were considered ungual in 73% (n = 75) and periungual in 27% (n = 28) of the cases. Sonography showed their nature (solid or cystic), location, and extension as well as regional blood flow. In 35% of the cases, the use of sonography modified the clinical diagnosis, although the detailed anatomic information provided by sonography was useful in the planning of surgery in all cases. The addition of sonography was significant (P < .001) for the diagnosis of subungual exostosis and granulomas in comparison to clinical diagnosis.

CONCLUSIONS

Sonography is a noninvasive imaging method that can reliably detect common benign tumors and pseudotumors of the nail and provide precise data about their characteristics. This imaging modality can support diagnosis and surgery and can allow a better definition and improvement of the cosmetic outcome of the treatment.

Atypical glomus tumour of the wrist: a case report

Wrist glomus tumours are extremely rare. We report a case of an unusually large wrist glomus tumour with atypical presentation. Magnetic resonance imaging (MRI) findings correlated well to those previously described for digital glomus tumours. This rare differential should be considered when evaluating lesions around the wrist.

Clinical usefulness of variable-frequency ultrasound in localized lesions of the skin

BACKGROUND

High variable-frequency ultrasound is a recently available technique capable of clearly defining skin layers and deeper structures that also provides local perfusion patterns obtained in real time.

OBJECTIVES

The aim of the study was to assess the performance of variable-frequency ultrasound in the evaluation of skin lesions.

METHODS

We performed a retrospective study of 4338 skin ultrasound examinations in predominantly localized skin lesions, and in a group of 130 healthy controls. We determined ultrasound sensitivity, specificity, and statistical level of certainty, and compared ultrasound diagnoses with clinical diagnoses.

RESULTS

Referring diagnosis was correct in 73% of the lesions, and addition of ultrasound increased correctness to 97% (P < .001 for the difference). Ultrasound overall sensitivity was 99%, specificity was 100%, and statistical diagnostic certainty was 99%

LIMITATIONS

Ultrasound in its current version cannot detect lesions that are epidermal only or that measure less than 0.1 mm in depth.

CONCLUSIONS

Ultrasound is a reliable adjuvant for the accurate and precise diagnosis of skin lesions.

Tumores glômicos subungueais: achados de imagem

OBJETIVO: Analisar os principais aspectos de imagem dos tumores glômicos subungueais. MATERIAIS E MÉTODOS: Realizado estudo retrospectivo de oito casos de tumores glômicos subungueais, pertencentes a arquivos de duas clínicas particulares de Goiânia, GO, Brasil. Foram obtidas radiografias em cinco casos, ultrassonografia com Doppler em seis casos e ressonância magnética em cinco casos. RESULTADOS: A idade média de acometimento no presente estudo foi de 39 anos, com predomínio do sexo feminino, na proporção de 7:1. Os tumores não apresentaram predileção por nenhum dedo e a maioria localizava-se na região subungueal mediana. A radiografia foi positiva em três casos, demonstrando erosões de pressão. A ultrassonografia com Doppler foi positiva em cinco casos, evidenciando nódulo sólido, hipoecoico e hipervascularizado. A ressonância magnética, em todos os casos, demonstrou nódulo sólido com hipossinal em T1, hipersinal em T2 e captação homogênea do meio de contraste. Em todos os pacientes foi realizada excisão cirúrgica com confirmação anatomopatológica. CONCLUSÃO: A maioria dos tumores glômicos tem localização subungueal. O diagnóstico é clínico, porém geralmente tardio. Os métodos de imagem auxiliam no diagnóstico precoce, além auxiliar no planejamento terapêutico, cujo tratamento de escolha é a excisão cirúrgica.

Surgical treatment of subungual glomus tumor: a unique and simple method

BACKGROUND

The glomus tumor, described as a painful subcutaneous nodule, commonly occurs in subungual regions and is accompanied by tenderness and temperature sensitivity. In treatment of subungual glomus tumor, surgical excision is known to be the only curative method. Under surgical approach, it is challenging to minimize postoperative nail deformity and to reduce tumor recurrence.

OBJECTIVE

To evaluate the efficacy and safety of surgical treatment of subungual glomus tumor using simple blunt dissection.

MATERIALS AND METHODS

Twenty-three patients diagnosed with subungual glomus tumor underwent surgical procedure using a dorsal transungual approach. A single linear incision was made above the tumor, and the exposed mass was meticulously dissected with the opposite end of a single-end probe, and the tumor "popped up." Recurrence of symptom, tumor recurrence, and local complication were evaluated through long-term follow-up.

RESULTS

After a mean follow-up period of 30 months, only one case recurred, and partial-thickness skin necrosis occurred around the tourniquet site. There was no postoperative nail deformity.

CONCLUSIONS

In treatment of subungual glomus tumor, meticulous simple blunt dissection using a transungual approach led the tumor to "pop up" from the tumor bed. This unique and simple method of treating subungual glomus tumor showed low recurrence and minimal complications.

Role of high-variable frequency ultrasound in preoperative diagnosis of glomus tumors: a pilot study

BACKGROUND

Accurate preoperative imaging of glomus tumors improves the outcome of surgery. Currently, MRI is frequently recommended for preoperative assessment although this requires the use of intravenous contrast media and may be less efficient at detecting tumors <3 mm in diameter. Recent developments in high-variable frequency ultrasound (HVFUS) mean re-evaluation of the possible role of ultrasound in the preoperative detection of glomus tumors appears appropriate.

OBJECTIVE

To assess the capabilities of contemporary HVFUS in relation to preoperative detection and characterization of glomus tumors.

METHODS

Seven patients (all women, aged 38-66 years, mean age 51.3 years) suspected on clinical grounds of having a glomus tumor were evaluated with high-resolution color Doppler ultrasound using a compact linear probe that varies from 7 to 15 MHz in frequency. The results were compared with histology.

RESULTS

The tumors and their exact location were identified in all cases. The tumors appeared as hypoechoic nodules with high vascularity in the nail bed, together with remodeling of the underlying bone. Small tumors (0.9 mm depth) were also identified. Arterial flow was identified inside all tumors. Peak systolic velocity varied greatly, but the mean was 11.3 +/- 9.1 cm/sec (range: 3.7-26.1 cm/sec).

CONCLUSION

Recent developments in HVFUS have made it possible to identify small glomus tumors in real time and with high resolution. The procedure does not require administration of intravenous contrast media and provides good information about lesional blood flow and the surrounding structures. These results suggest that HVFUS may play a larger role in the preoperative assessment of glomus tumors in the future.

Calcified glomus tumor of the shoulder. A case report

The authors report a case of calcified glomus tumor of the shoulder in a 54-year-old woman. The nonspecific clinical findings and the noncharacteristic imaging results made diagnosis of this tumor impossible before surgery. The diagnosis was confirmed by a biopsy. The outcome after surgical resection was excellent.

Extradigital glomus tumors: a 20-year experience

OBJECTIVE

To review a large series of extradigital glomus tumors in order to gain a better understanding of their presentation and provide guidelines to aid in their diagnosis and treatment.

PATIENTS AND METHODS

We performed a retrospective review of all extradigital glomus tumors seen at our institution during a 20-year period (1985-2005) to document the incidence of the classic triad of symptoms, the duration of symptoms, the contribution of imaging to making a definitive diagnosis, and the effectiveness of treatment.

RESULTS

Fifty-six different patients with extradigital glomus tumors presented as follows: glomus tumors in the hand (3), wrist (4), forearm (11), elbow (4), arm (4), shoulder (2), buttock (1), thigh (5), knee (10), leg (3), ankle (2), foot (2), back (1), nose (1), cheek (1), ear lobe (1), and trachea (1). Forty-eight patients presented with pain and localized tenderness, but only 1 patient presented with cold Intolerance. The average duration of symptoms was greater than 7 years, with most patients being evaluated previously and having their conditions misdiagnosed. Magnetic resonance imaging proved to be the most useful modality for localization of these lesions. Surgical resection was the definitive treatment and generally provided immediate and sustained pain relief.

CONCLUSIONS

Extradigital glomus tumors are not a rare subgroup of glomus tumors. Treatment outcomes are excellent, but misdiagnosis and delayed diagnosis are common. Improved guidelines regarding symptoms and diagnosis of these neoplasms may reduce the morbidity, ensuing chronic pain, and psychiatric consequences of delayed diagnosis or misdiagnosis.