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

Outcomes of the Transungual Approach in 56 Consecutive Digital Subungual Glomus Tumours

Background: Glomus tumour is a painful small tumour of the glomus body commonly located under the nail bed. The aim of this study is to evaluate the correlation of clinical diagnosis with MRI findings, determine the prevalence of the tumour at different subungual locations and determine the differences in outcomes (if any) between a longitudinal and a transverse nail bed incision for excision of the tumour. Methods: This retrospective study of 56 subungual glomus tumour was conducted from May 2010 to December 2021. Data with regard to gender, age at presentation, digit involved, presenting symptoms, duration of symptoms, clinical signs, need for MRI, anatomical location, surgical approach (longitudinal versus transverse), histopathology result, period of follow-up and complications were recorded. Results: All 56 (100%) patients presented with classic triad of symptoms. The average duration of symptoms was 52.9 months (range: 3-204 months). Eleven (20%) tumours were in the sterile matrix, 38 (68%) at the junction of sterile and germinal matrix and 7 (12%) in the germinal matrix. The tumours were excised through the longitudinal incision in 31 (55.3%) patients and transverse incision in 25 (44.7%). One (1.8%) tumour was intraosseous that was diagnosed intraoperatively and excised successfully. Average follow-up was 35.4 months (range: 6-120 months). There was no difference in outcomes (pain or nail deformity) between the two incisions. One patient (1.8%) has persistent pain that was due to a missed satellite lesion in the same digit. This was excised later with resolution of symptoms. There were no recurrences and all patients were cured after excision of tumour. Conclusions: Diagnosis of glomus tumour is usually clinical, and most are located at junction of sterile and germinal matrix. Tumour can be excised either by longitudinal or transverse nail bed incisions without any change of treatment outcome. Level of Evidence: Level IV (Therapeutic).

Nail-preserving excision of glomus tumor in the second toe: Case report and literature review

INTRODUCTION

This case report describes the diagnosis of a glomus tumor in the second toe of a 38-year-old female, followed by surgical treatment utilizing a transungual approach to preserve the nail. This study highlights the diagnostic challenges and surgical strategies to treat such tumors while preserving nail integrity.

PATIENT CONCERNS

Pain occurred once a week, but over time, it increased, and just before seeking medical attention, she experienced pain more than 5 times a day. The pain worsened when cold water touched her toe.

DIAGNOSIS

We observed a slight hump indicating nail plate deformity, and the patient exhibited severe pinpoint tenderness (positive Love test) in the affected area. Color duplex ultrasound was performed for further investigation, revealing a hypervascular hypoechoic nodule measuring 0.5 cm in size at the nail bed of the right second toe.

INTERVENTION

The surgery was performed under digital nerve block anesthesia using a modified transungual nail-preserving approach for the excision of the glomus tumor.

OUTCOMES

The pain that was reported prior to the surgery has improved postoperatively, and the recovery has been uneventful without any other complication.

CONCLUSION

This paper provides a comprehensive examination of a rare glomus tumor in the second toe, elucidating both diagnostic intricacies and treatment modalities. It emphasizes the dual necessity of achieving total tumor excision while also considering aesthetic outcomes. The insights presented herein are intended to serve as valuable guidance for clinicians confronted with similar clinical scenarios, underlining the delicate interplay between effective tumor management and the preservation of cosmetic integrity.

En Bloc Excision and Bone Grafting for Monostotic Multiple Intraosseous Glomus Tumors of the Distal Phalanx: A Case Report

CASE

Glomus tumors of the hand are rare tumors that occur predominantly in the subungual region. Though multicentric glomus tumors have been reported in the subungual region involving the nailbed, monostotic multiple intraosseous glomus tumors have not been reported so far. We report a case of a 36 year-old woman who presented with a 5-year history of intermittent thumb pain, aggravated with exposure to cold or pressure. A glomus tumor of the thumb was excised, but symptoms returned 3 months later. She ultimately underwent curettage with bone grafting of a recurrent glomus tumor at the same site, and has been free of symptoms for 1.5 years.

CONCLUSION

Intraosseous glomus tumors may present as multiple synchronous lesions. This, to the best of our knowledge, is the first case report of monostotic multiple intraosseous glomus tumors.

My journey in hand surgery: combining patient care, clinical and basic science research

This review is about my clinical and research journey in hand surgery. The journey has been a worthwhile and meaningful one, especially when I felt there were areas I could influence management, whether this be rare cases, common conditions or where a suggested algorithm may be helpful. I also had the unique privilege of working with geneticists, which has resulted in clinical-pathological publications that could influence patient management, as shared from a clinician's perspective. It is hoped this article will inspire young clinician scientists to pursue a journey of collaboration with other researchers.

Glomus tumor of the scapular neck with axillary nerve compression at the shoulder. A case report

Background

Glomus tumors, also known as benign acral tumors are extremely rare. Previous glomus tumors from other regions of the body have been linked to neurological compression symptoms, however axillary compression at the scapular neck has never been described.

Case presentation

Here, we report a case of axillary nerve compression in a 47-year-old man, secondary to a glomus tumor of the neck of the right scapula, initially misdiagnosed with biceps tenodesis performed and no pain improvement. The magnetic resonance imaging demonstrated a well-contoured, 12 mm tumefaction at the inferior pole of the scapular neck T2-hyperintense and T1-isointense and interpreted as a neuroma. An axillary approach allowed the dissection of the axillary nerve, and the tumor was completely removed. The pathological anatomical analysis resulted in a nodular red lesion measuring 14 × 10 mm, delimited and encapsulated with a definitive diagnostic of glomus tumor. The neurologic symptoms and pain disappeared 3 weeks after surgery and the patient reported satisfaction with the surgical procedure. After 3 months, the results remain stable with a complete resolution of the symptoms.

Conclusions

In cases of unexplained and atypical pain in the axillary area, and to avoid potential misdiagnoses and inappropriate treatments, an in-depth exploration for a compressive tumor should be performed as a differential diagnosis.

Extradigital glomus tumour of the thigh causing 8 years of undiagnosed debilitating pain

A woman in her mid-50s was referred to a plastic surgeon with an 8-year history of undiagnosed, localised severe, reproducible pain of the right thigh. Treatment with oral and topical analgesics, corticosteroids, acupuncture and physiotherapy did not provide symptom relief. She was referred to multiple specialists over the preceding 8 years including chronic pain physicians, physiatry, orthopaedic surgery and plastic surgery. Investigations including sonographic and MRI eventually revealed a non-specific soft tissue abnormality in the area of tenderness, which was excised en bloc. Histopathology revealed an extradigital glomus tumour. The patient's symptoms immediately and permanently resolved postexcision.Physicians seeing patients suffering from undiagnosed focal, reproducible pain should consider extradigital glomus tumours in their differential diagnosis. Workup for extradigital glomus tumour includes focused sonographic or MRI over the area of pain. Additionally, local injection of an anaesthetic agent can be used to assist with diagnosis.

Hand and Foot Glomus Tumors: Significance of MRI Diagnosis Followed by Histopathological Assessment

Introduction Glomus tumors are benign lesions with hamartomatous proliferation in the neuromyoarterial glomus bodies. Glomus tumors are small, reddish, painful blue nodules usually underneath the fingernail. Objectives This study is mainly focusing on magnetic resonance imaging (MRI) findings of glomus tumors on T1, T2, short inversion time inversion recovery (STIR), and post-gadolinium images. Further study of clinical and histopathological findings to support the radiological diagnosis. Material & methods The retrospective study included an elaborate study of MRI imaging findings of 24 cases of glomus tumors of the hand and leg at a tertiary care center in Udaipur. Patients with imaging findings confirmed on histopathology were included in the study. MRI study was conducted using a 3-T MR unit and a high-spatial-resolution module. Results A total of 24 cases of glomus tumors were diagnosed during the six years between January 2015 and November 2020. Out of 24 patients, 14 were female and 10 were male. The most common site of involvement was a hand, followed by a foot. All 24 cases showed isointense to hyperintense lesions on T2-weighted images with a conspicuous hyperintense lesion on STIR images. Further histopathological examination confirmed the diagnosis showing nests of monomorphic tumor nuclei arranged in a perivascular pattern. Conclusion Glomus tumors can present with variable pain. A high index of suspicion is needed for diagnosis. Contrast MRI has a significant role in the diagnosis of glomus tumors. The clinical and histopathological picture further confirms the diagnosis. MRI imaging is further supportive to differentiate postoperative fibrosis from residual or recurrent tumors.

Unusual glomus tumor of the lower leg: A case report

BACKGROUND

Glomus tumors are rare neoplasms, usually found on the fingers or toes. Glomus tumours that occur in the lower leg are even rarer and is likely to be misdiagnosed or underdiagnosed. This article will document the diagnosis, treatment, and follow-up of a rare glomus tumor of the lower leg, which had been misdiagnosed for up to 15 years.

CASE SUMMARY

The patient was a A 36-year-old woman who had suffered from localized pain in her left lower leg for 15 years. After a complete physical examination, a glomus tumor on her lower leg was considered and removed surgically. The specimen was pathologically diagnosed as a glomus tumor. There was no relapse at a 4-year follow-up.

CONCLUSION

Correct diagnosis and complete removal of the glomus tumor is important.

Sellar Glomus Tumor Misdiagnosed as Pituitary Adenoma: A Case Report and Review of the Literature

Glomus tumor is a rare mesenchymal tumor with an organ-like structure. Sellar glomus tumors are extremely rare with only six reported cases in the literature. Because of the lack of special clinical manifestations and imaging features, the disorder may be easily misdiagnosed as other sellar tumors, especially pituitary adenomas. Here, the present study showed a case of a 69-year-old male with hypopituitarism who was preliminarily misdiagnosed as non-functional pituitary adenoma.

Suprascapular glomus tumor: an unusual cause of chronic shoulder pain

Glomus tumors (GT) are rare mesenchymal tumors that develop in the subungual digital region. Extradigital GTs are very rare, with atypical clinical features. We report the case of a 63-year-old male with a five-year history of intermittent shoulder pain, where an excisional biopsy confirmed the diagnosis of a glomus tumor.

Clinical, histopathological and immunohistochemical features of glomus tumor of the nail bed

Purpose: Glomus tumors account for 1–4% of benign hand tumors. In 65% of cases, it is located in the nail bed. Its rarity makes misdiagnosis problems relatively common. Symptomatology is characterized by the hallmark symptomatic triad. Imaging investigations may guide the diagnosis, but the diagnosis is made by pathological examination doubled by immunohistochemical (IHC) markers. Patients, Materials and Methods: We studied a group of seven female patients, aged 28 to 56 years. Clinical examination revealed the presence of the characteristic symptomatic triad. Ultrasound imaging tests were performed. Results: Anatomopathological examination made a diagnosis of glomus tumor in all seven cases. IHC staining showed that tumor cells were positive for alpha-smooth muscle actin (α-SMA) and h-caldesmon in all seven cases and negative for cluster of differentiation 34 (CD34) in 72.14%. IHC stainings for p63, S100, cytokeratin (CK) AE1/AE3 were negative in all cases. The clinical diagnosis completed by ultrasonography was histopathologically confirmed in all cases. Conclusions: Although the glomus tumor is a rare lesion, we need to be familiar with it because a diagnostic delay also implies a treatment delay which will lead to amplified suffering and even real disability due to the high-intensity pain in these cases.

Extradigital Glomangioma of the Cutaneous Chest Wall

Glomus tumors (GTs) are rare benign tumors as a result of hyperplasia of glomus body. GT most commonly involves the subungual areas and rarely involves extra-digital sites. The clinical presentation of a glomus tumor is a triad of symptoms consisting of pain, cold intolerance, and pinpoint tenderness. Even though glomus tumors are benign, they can infrequently be malignant. Despite their benign nature, these lesions can cause disabling symptoms, therefore proper diagnosis and treatment is important. In this report, we present a 35-year-old Saudi male with a painful lesion on the right side of the chest wall at the posterior axillary line for seven years, with recent progressive growth and symptoms. Diagnosis of extra-digital glomangioma of the chest wall in this patient was confirmed by histopathology. The patient was managed by complete surgical excision of the lesion with the resolution of pain and without recurrence.

Rare glomus tumor formation following trauma to the first digit

INTRODUCTION

Glomus tumors are rare and few cases are reported in the literature. They typically occur in females on the digits of the hands.

CASE PRESENTATION

We report a case of a 30 year-old woman who presented with a mass that developed on the distal tip of her right thumb after traumatic injury. Magnetic resonance imaging (MRI) was conducted and mass resection was performed. Histopathology confirmed that the mass was a glomus tumor.

CLINICAL DISCUSSION

Clinical presentations of glomus tumors are typically non-specific, mainly consisting of a small mass with chronic pain, with a lengthy time to diagnosis and potentially improper management. MRI is the preferred diagnostic step, followed by curative surgical excision and pathological confirmation.

CONCLUSION

Glomus tumors can cause significant discomfort for patients, and clinicians should be aware of the rare diagnosis when treating painful masses on the extremities, as surgical excision is often curative.

Clinical characteristics and differences among 802 acral tumors by anatomical sites

BACKGROUND

Acral skin tumors are common, but there are few literature reviews regarding their incidence.

OBJECTIVES

To investigate the clinical characteristics and differences in incidence of benign and malignant acral tumors by anatomical site.

METHODS

A retrospective review of 802 patients with acral skin tumors confirmed by skin biopsy between January 2010 and December 2019 was conducted. Age, sex, duration, symptoms, and sites were obtained from medical records and photographs.

RESULTS

The mean age of onset was 43.8 years with a male-to-female ratio of 1:1.41, and the mean duration was 68.8 months. Most were asymptomatic (66.7%). In total, 802 acral tumors were identified: 512 (63.8%) were benign and 290 (36.2%) were malignant. The most common benign tumors were benign melanocytic lesions (n = 239), and the most common malignant tumors were melanoma (n = 234). The most common site was the sole (n = 408). Benign melanocytic lesions, melanoma, and epidermal cyst were more frequent on the foot, and pyogenic granuloma, glomus tumor, hemangioma, and mucous cyst were more frequent on the hand. Glomus tumor, fibroma, mucous cyst, and osteoma were more frequent on the nail portion, and benign melanocytic lesions and epidermal cyst were more frequent on the non-nail portion.

CONCLUSIONS

This study reports the incidence of various benign and malignant acral tumors according to site, and we believe the results will be helpful in making a diagnosis in the clinic.

Tumors of the Hand and the Wrist

Most tumors of the hand and the wrist are benign; however, malignant conditions can mimic benign tumors and must be worked up accordingly. Advanced imaging should be followed by biopsy before definitive treatment of tumors of unknown diagnosis. The most common soft-tissue masses in the hand and the wrist are ganglion cysts, whereas the most common bone tumors are enchondromas.

Hand Masses

Hand and wrist soft tissue masses may be classified as pseudotumors, benign neoplasms, or malignant neoplasms. The vast majority of hand lesions are benign. Consideration of the location of the lesion and its imaging characteristics often leads to a specific diagnosis. Pseudotumors discussed in this article are ganglion cysts, accessory muscles, and inflammatory lesions. True tumors are described according to their tissue type: nerve sheath tumors, adipocytic tumors, so-called fibrohistiocytic tumors, pericytic tumors, and vascular lesions. We also outline the imaging features of masses encountered in the hand and wrist.

Glomus Tumor: "A-Not-So-Rare" Cause of Chronic Shoulder Pain-A Case Report and Literature Review

Case

A 61-year-old male presented with chronic shoulder pain resistant to conservative treatment. Imaging identified a nodular lesion in the deltoid muscle, which histology after resection identified as a glomus tumor. After surgery, the patient became asymptomatic and at 4-year follow-up has not shown signs of recurrence.

Conclusion

Glomus tumors around the shoulder should be considered when investigating chronic shoulder pain, as they are more common than thought. Despite being elusive, when diagnosed, excellent outcomes may be expected, with surgery resection being curative.

Concepts, Role, and Advances on Nail Imaging

This review discusses, from a practical point of view, the most common imaging techniques and their applications in nail pathologies with some technical considerations. There are several imaging techniques for studying the nail, and all of them require proper devices and trained operators. The highest axial resolution and a more extensive range of applications are provided by ultrasound, which currently is the first-choice imaging technique for evaluating nail conditions. A correlation of state-of-the-art clinical and imaging figures supports the review of this topic.

Comparing the Diagnostic Accuracy of Clinical and Radiological Measures in Hand Soft-Tissue Masses

Introduction

Imaging modalities are imperative to aid in diagnosing hand soft-tissue tumors. Limited insight is available into the diagnostic accuracy of history and physical examination in comparison to radiological diagnosis. 

Methods

In this retrospective analysis, data of patients with hand soft-tissue tumors that were surgically treated and diagnosed through biopsy were extracted; taking this as a reference, the sensitivity, specificity and positive and negative predictive values and likelihood ratios of the clinical approach and radiological tools were contrasted against each other. 

Results

Data of a total of 34 patients were revised in this study. With a mean age of 40.1 years, the most common anatomical area of the hand to be affected by the tumors was the index (n = 7, (18.9%); ganglion cysts were the most common tumor (n = 9, 26.5%) and magnetic resonance imaging was the most commonly used imaging modality (n = 24, 70.6%). Clinical diagnosis scored a sensitivity and specificity of 44.4% and 100% in ganglion cysts and 62.5% and 86.2% in giant cell tumors in contrast to the sensitivity and specificity of 66.7% and 100% for ganglion cysts and 50% and 90% for giant cell tumors scored by radiological modalities.

Conclusion

Clinical diagnosis could be non-inferior to radiological diagnosis, yet radiological examination remains a valuable adjunct to clinical examination. Larger scale, prospective studies are required before generalizing our results.

Clinical and onychoscopic characteristics of subungual glomus tumor: a cross-sectional study

BACKGROUND

Subungual glomus tumor is a relatively uncommon entity with varied clinical presentations which may lead to diagnostic delays. Onychoscopy can be used as an evaluation tool in routine evaluation of glomus tumors.

OBJECTIVES AND METHODS

With an aim to characterize the onychoscopic features of subungual glomus tumors, we analyzed 15 cases presenting over 3 years, in this observational study. The clinical, onychoscopic, radiological, and operative findings in these patients were evaluated and correlated depending on the location and extent of the lesions.

RESULTS

All 15 patients (11 female and 4 male) had pain as the presenting symptom and fulfilled the classic triad of paroxysmal pain, cold sensitivity, and positive Love's pin test. Clinical nail plate findings included onycholysis, onychorrhexis with distal splitting, and onychoschizia, while nail bed and matrix findings included localized erythematous and bluish patches, longitudinal erythema, and altered lunula. Onychoscopy corroborated the clinical findings and revealed a more extensive area of involvement in five cases. Definitive onychoscopy findings included a localized structureless erythema interspersed with bluish and patchy whitish areas (five cases of nail bed and six nail matrix tumors) and a "candy-cane appearance" (six cases, all large and lobulated nail matrix tumors). MRI reported the tumor in 13 cases, while two nail matrix tumors were missed. Transungual excision revealed tumors larger in size than predicted by MRI. The presence of candy-cane appearance was consistent with lobulated matrix tumors.

CONCLUSION

Onychoscopy improves the intraoperative detection of location and extent of subungual glomus tumors. Nail bed and nail matrix glomus tumors can have distinctive onychoscopic features that may help in better surgical planning.

A patient with chronic fingertip pain

Isolated chronic fingertip pain is an uncommon presentation with a broad differential diagnosis, including but not limited to, subungal neuroma, subungal haematoma, subungal exostosis and glomus tumour. We present an interesting case of a young lady with debilitating chronic fingertip pain diagnosed with a glomus tumour of her right index finger. Surgical excision provided complete resolution from pain, return to work and restoration of quality of life. Here we discuss clinical and radiological features of this rare benign neoplasm.

Extradigital glomus tumor of the anterior knee

The benign glomus tumor is an uncommon cause of crippling pain most commonly associated with the fingers. This sheep in wolf’s clothing is identified by careful examination, confirmed by MRI, and often resolved with a simple procedure. Here we present a patient with chronic knee pain of 21 years duration.

Ultrasound features of the subungual glomus tumor and squamous cell carcinomas

BACKGROUND

Nail tumors often pose a significant challenge for the clinician, as they are burdened by a high delay in diagnosis and paucity of clinical signs in the early stage. In most cases, the onset of pain or nail plate dystrophy leads to imaging investigations such as plain radiography, magnetic resonance imaging, and ultrasonography (US) when surgery is pending.

MATERIAL AND METHODS

A 2-year monocentric study evaluated the histologically confirmed cases of subungual glomus tumor (GT) and squamous cell carcinoma (SCC) with a pre-surgical US assessment, and reviewed their sonography features. A total of 7 digital GTs and 6 SCCs of the nail were collected.

RESULTS

GT and SCC are easily distinguishable on US. Compared to SCC, GT was positively associated with an ovoid shape, well-defined borders, bone cup-scalloping without cortical erosion, and a rich intralesional vascular pattern (P < 0.05). Vice versa, SCC was significantly correlated with irregular shape, ill-circumscribed margins, an infiltrative growth pattern with peripheral hypoechoic foci, posterior acoustic shadow, cortical erosion, and a highly vascular multipolar peripheral pattern (P < 0.05).

CONCLUSION

The rapid assessment of GT and SCC sonographic features may contribute to reduce diagnostic delay, expedite management, and decrease the risk of surgical relapse.

Recurrent glomangioma ("true" glomus tumor) of the middle ear and mastoid

Objective

To review current literature and experience with glomangiomas, or true glomus tumors of the middle ear and mastoid as well asto report on the exceptionally rare case of a glomangiomastemming from the middle ear space with multiple recurrences.

Methods

Review of existing world literature and description of personal experience with rare cases of a glomangioma of the middle ear and mastoid.

Results

Review of existing literature revealed two cases of patients presenting with tinnitus and hearing loss refractory to medical management. Both patients were ultimately diagnosed with glomangioma on histopathology. Complete surgical excision is thought to be curative.

Patient

A 36-year-old woman presented with a rare case of a glomangioma of the middle ear presenting with unilateral hearing loss. She was noted to have a mass behind the tympanic membrane. Imaging revealed a diffuse mass filling the mastoid air cells. Imaging characteristics and histology were consistent with a glomangioma.

Intervention

Initial resection via mastoidectomy using a postauricular approach. The tympanic membrane was reconstructed with temporalis tissue. Follow-up revision tympanomastoidectomy was performed upon recurrence of disease. The chorda tympani were sacrificed due to tumor involvement. The incus and head of the malleus were removed to gain better access to the tumor. The ossicular chain was reconstructed with a Goldenberg Total Ossicular Prosthesis.

Main outcome measure

Recurrence of disease.

Follow-up

In the 67 months since her most recent surgery, there has been no evidence of recurrence by CT or physical exam.

Conclusion

Glomangioma of the middle ear represents an exceptionally rare entity that can present in a similar fashion to a paraganglioma.

A bump: what to do next? Ultrasound imaging of superficial soft-tissue palpable lesions

Soft-tissue palpable lesions are common in clinical practice, and ultrasound (US) represents the first imaging option in the evaluation of a patient with a soft-tissue swelling. A full and systematic US assessment is necessary, however. This includes grayscale, color- and power-Doppler, spectral-Doppler, and possibly elastography facilities, as well as a trained operator. Several lesions showing characteristic US features can be diagnosed confidently, without any further work-up, and the high spatial resolution of ultrasound in the superficial layers can be a powerful tool to discriminate their etiologies. Second-level options, to be reserved for indeterminate cases or those suspected malignant at initial ultrasound, include magnetic resonance imaging, percutaneous fine-needle aspiration or biopsy, and surgical-excision biopsy. In this article, we discuss the proper US approach for addressing superficial soft-tissue lesions.

Glomus tumour of the fourth toe: case discussion and review of literature

This is a case report with literature review and discussion of current diagnostic studies and management of a rare case of glomus tumour in the fourth toe of a 36-year-old male patient.

Glomus tumour of the male urethra: an unusual diagnostic

A 56-year-old man was referred to a reconstructive urologist for evaluation of a tender nodule in the penoscrotal area. Penile Doppler ultrasound showed a non-compressible mass with internal vascularity within the corpora spongiosum, and MRI identified an enhancing, solid mass arising from the ventral aspect of the urethra. Surgical resection warranted partial excision and reconstruction of the urethra, which was achieved by a dorsal onlay buccal mucosal graft urethroplasty through a perineal incision with penile invagination. The histopathology report concluded to an invasive, high-grade urothelial carcinoma, for which an aggressive oncological approach was considered. However, discussion with the pathology team led to the identification of a glomus tumour for which the patient did not need additional procedures. Urethral glomus tumours are extremely rare and should be included in the differential diagnosis of urethral masses. This case exemplifies the importance of teamwork in the management of uncommon cases.

Surgical Resection of Occult Subungual Glomus Tumors: Cold Sensitivity and Sonographic Findings

PURPOSE

We surgically treated subungual masses that were suspected glomus tumors, although definitive clinical and radiological findings were lacking. We report the outcomes of a retrospective case series.

METHODS

Of 42 patients treated by surgical resection between March 1996 and December 2015, 7 who met our inclusion/exclusion criteria were evaluated. At least 1 symptom of the typical triad (temperature sensitivity, severe pain, and localized tenderness) was absent, and computed tomography (CT) and magnetic resonance imaging (MRI) findings were normal. After ultrasonographic evaluation, we resected the masses using a transungual approach or a nail-preserving method. After pathological confirmation of the diagnosis, we followed all patients for at least 2 years to evaluate tumor recurrence and nail deformity.

RESULTS

In 5 patients, cold sensitivity was the only symptom; no physical finding was suggestive of a glomus tumor. Tenderness was evidenced by the 2 patients who lacked cold sensitivity. None of the 7 patients exhibited CT or MRI abnormalities, but small acoustic shadows were evident in 4 patients, and blood-rich nodules were noted in 2 patients. The mean diameter of the 7 tumors was 2.1 mm, and pathological examination revealed typical glomus bodies. No major surgery-associated complication developed during follow-up. The final mean visual analog scale score (assessing pain) improved to 0.3 from the mean preoperative value of 3.6.

CONCLUSIONS

Small glomus tumors exhibit few traditional symptoms and signs and no definitive radiological CT/MRI finding. However, cold sensitivity alone is a powerful surgical indication, and occasionally, ultrasonographic findings are useful even in the absence of CT/MRI findings.

Factors affecting surgical outcomes of digital glomus tumour: a multicentre study

This was a retrospective, multicentre study using data from four medical institutions of 72 patients of histologically confirmed digital glomus tumour removed by surgical excision. Mean follow-up period was 5.4 years. We investigated clinical outcomes and analysed the relationship between primary glomus tumour size, radiographic bony erosion, anatomic location, surgical approach, and surgical method as risk factors for recurrence. Complications and recurrence rate according to surgical approach and surgical method were compared. At final follow-up, recurrence was observed in five (6.9%) patients. Postoperative complications were observed in nine (12.5%), with two patients having numbness of fingertips, and seven having nail deformities. In a group with pulp lesions for which a direct approach was used and in a surgical loupe group, recurrence rates were high, however, this was not statistically significant. A nail-sparing approach and microscopic excision did not lower the incidence of nail deformities. No risk factors that significantly predicted recurrence were found.

LEVEL OF EVIDENCE

IV.

Extradigital Glomus Tumor with Atypical Neuritis Presentation

Glomus tumors are rare tumors of the arteriovenous junction that play a role in temperature regulation. They are most commonly found in the subungual finger. We present the case of a 77-year-old female with a chief complaint of a painful mass in her ulnar wrist. The differential diagnosis at the time was broad. Following a detailed history and physical exam, the etiology was believed to be that of a peripheral nerve sheath tumor. The patient was taken to the operating room for resection and biopsy of the mass. Histological evaluation confirmed that the mass was a glomus tumor. Our patient’s symptoms had completely resolved and functional status had improved to baseline by the time of her two-week postoperative clinic visit. This case report demonstrates the many complexities in the diagnosis of a glomus tumor and the important role of surgical treatment in obtaining relief from extradigital glomus tumors.

Recurrent Bleeding Neck Mass: a Case Report

An adult male presented to us with a recurrent, large bleeding tumour in the neck. We describe our approach to the patient, whose tumour was labelled as an atypical glomus on final histopathology. They are relatively uncommon in the head neck, and this case report with literature review is expected to add to our knowledge.

Tumores glómicos en el miembro superior. Revisión de la literatura e informe de 14 casos

Objetivo: Revisar los resultados del tratamiento quirúrgico de los tumores glómicos del miembro superior tratados en nuestro servicio de cirugía de la mano en los últimos 15 años y comparar con la bibliografía especializada los datos de una serie de 14 tumores operados.

Material y método: Se trataron 14 tumores glómicos en 14 pacientes: 7 hombres y 7 mujeres. La media de edad fue de 50,7 años (rango 31-70).

En todos los pacientes se anotó la zona de presentación del tumor, su aspecto macroscópico con registro fotográfico, la técnica quirúrgica y el resultado final, funcional y estético.

Resultados: En todos los pacientes se dieron presentaciones únicas y todos se curaron completamente con el tratamiento quirúrgico, pero en 2 hubo recidivas y uno de ellos debió operarse hasta 5 veces para erradicar el tumor completamente.

Conclusión: El tumor glómico, por su infrecuencia, es poco conocido fuera del ámbito de la cirugía de la mano y de la dermatología, de ahí la demora en el diagnóstico que padecen buena parte de los pacientes. Los de presentación extradigital no suelen sospecharse y su diagnóstico lo aporta el estudio anatomopatológico.

El tratamiento quirúrgico, consistente en la exéresis de la masa tumoral y el legrado de la cavidad ósea si la hay, es resolutivo en la mayor parte de los casos, si bien la tasa de recidivas es muy elevada, probablemente por haberse realizado una escisión incompleta.

La complicación más frecuente es de tipo estético, por deformidades de la uña en los tumores de presentación subungueal.

Glomus Tumor: Twenty-Year Experience and Literature Review

Glomus tumors are rare, usually benign, vascular hamartomas consisting cells resembling the smooth muscle cells of the normal glomus body. They can be solitary or multiple, whereas solitary tumors are majorly located on the digits. Digital glomus tumors most commonly appear in subungual region and show a strong female predominance. There are several classical symptoms, clinical tests, and imaging tools, such as X-ray, magnetic resonance imaging, and ultrasonography, which can provide good accuracy for clinical diagnosis. However, misdiagnosis and delayed diagnosis are still commonly observed because primary physicians are unfamiliar with classical symptoms and clinical tests. Complete surgical excision often can result in complete relief of symptoms. Recurrence is largely caused by incomplete excision, but repeated image study is recommended to rule out new or malignant lesions. This series is a retrospective review of 50 cases with glomus tumors managed at our institute. We aim to review the key aspects of glomus tumor and provide a simple guideline for earlier diagnosis and treatment.

Color Doppler ultrasound morphology of glomus tumors of the extremities

OBJECTIVE

The aim of this study was to investigate the value of color Doppler flow imaging (CDFI) in the diagnosis of glomus tumors in the extremities.

METHODS

Sonography results of 62 nodules of 50 patients with glomus tumors in the extremities confirmed by surgery and pathology were analyzed retrospectively.

RESULTS

The sex ratio in the group of 50 patients was (female:male) = 5.25:1. Glomus tumors were more common in women aged 30-40 years. 84 % (42/50) of glomus tumors occurred in the fingers, with the thumb being the most common. 2D results showed that 64.52 % (40/62) of 62 nodules were hypoechoic, 30.65 % (19/62) were heterogeneous echo, 4.84 % (3/62) were hyperechoic; 64.52 % (40/62) had a clear border, while 35.48 % (22/62) had an unclear border. CDFI showed that 38.71 % (24/62) had visible rich blood in the tumor, 35.48 % (22/62) had little visible blood in the tumor, and 25.81 % (16/62) had no significant intratumoral blood flow. Of the 50 patients, 92 % (46/50) showed a fixed contact pain, were sensitive to cold stimuli, which was improved by hot water and air, and for which anti-inflammatory treatment was ineffective.

CONCLUSION

Glomus tumors in the extremities had certain ultrasound features, and its internal blood flow was diverse. Understanding this feature may be helpful for the diagnosis of non-typical glomus tumors.

Glomus tumor of the anterior urethra: A rare case report and review of the literature

Glomus tumors are rare and benign neoplasms, which normally originate from peripheral soft tissue. To date, reported cases of glomus tumor occurring in genitourinary tract, particularly in the urethra, are exceedingly rare. The present study presented a rare case of glomus tumor of the anterior urethra in a 42 year-old male, his main complaints were a history of anterior urethra pain for 3 years, and a palpable and tender mass in the urethra for 2 weeks. Urethrocystoscopy examination and the resection of the urethral mass were performed. Pathological and immunohistochemical examination revealed that the mass was a benign glomus tumor. The patient remained in good condition by 6 month follow-up, and revealed no problems or recurrence following surgery. This is the first case, to the best of our knowledge, to present a glomus tumor occurring in a male's urethra and the present report provided a supplementary review for the previous cases and the literature.

Extradigital Glomus Tumor-a Rare Cause for Undiagnosed Chronic Pain in Unusal Sites

Glomus tumor is a benign vascular tumor derived from the modified smooth muscle cells of the glomus body. The single most common site is the subungual region of the finger, but other common sites include the palm, wrist, forearm, and foot. In this article, we present a rare situation of glomus tumor occurring on the back of the chest over the scapular area in an elderly male patient. The tumor cells exhibited positive expression for CD34 and smooth muscle actin. This paper highlights the fact that a glomus tumor is a benign neoplasm that may occur in multiple locations. Therefore, the significance of a histological and immunohistochemical approach for a correct characterization of this lesion is required.

A recurred subungual glomus tumour of the thumb

Glomus tumours are rare benign neoplasms arising from the glomus body, accounting for 1-5% of all soft-tissue tumours of the hand. The diagnosis of glomus tumour is frequently delayed, varying from 3 to 15 years. We present a case of a recurred glomus tumour of the thumb where symptoms persisted for a period of 6 years after an attempted surgical excision. The patient presented with classical symptoms of localised tenderness, cold sensitivity and excruciating pain on touch. Findings on radiograph, ultrasonography and contrast-enhanced MRI further supported the diagnosis. Complete surgical excision, the only recommended treatment, resulted in complete symptomatic relief to the patient. This case report highlights the importance of meticulous complete excision and clinical awareness of the disease among primary care physicians.

Glomus tumour

Glomus tumours are rare tumours accounting for only 1-5% of soft tissue tumours of the hand. They are described classically in the subungual region. We present the case of a 32-year-old woman with a late diagnosis of a glomus tumour that had caused her excruciating pain. Clinical examination was positive for Hildreth's sign and the Love test. Magnetic resonance imaging delineated the tumour, which was excised and confirmed histologically. This case highlights the continued delay in diagnosis of glomus tumours as well as the use of imaging in diagnosis and planning of surgery.

Glomus tumours of the hand: Review of literature

Glomus tumours are rare benign vascular neoplasms commonly found in the hand particularly in subungual region. Though, its aetiology remains largely unknown, several hypotheses have been made to explain the etiopathogenesis and cause of pain. These tumours usually present as a bluish or pinkish red discolouration of the nail plate with classical triad of localised tenderness, severe pain, and cold sensitivity. Nevertheless, differential diagnosis of other painful tumours, such as leiomyoma, eccrine spiradenoma, haemangioma, neuroma, osteochondroma, or mucous cyst should always be kept in mind while evaluating a patient with severe pain in the tip of the finger. In addition to the different clinical tests including Love's pin test, Hildreth's test, and trans-illumination test, imaging studies such as magnetic resonance imaging (MRI), ultrasonography, and radiography are often helpful in the diagnosis. Complete surgical excision is a must to get complete relief from the symptoms and to avoid recurrence. Several approaches have been described in the literature. Different surgeons may have different choices and may prefer one approach over the other depending on the anatomical location of the tumours. The purpose of this article is to review the important aspects of glomus tumours in hand concerning their aetiology, clinical presentation, diagnosis, management, and recurrence.

Glomus Tumors in the Foot: Case Series

Glomus tumors are painful, benign neoplasms that frequently are associated with delayed diagnosis. Commonly in the hand, they rarely present in the foot. The purpose of this case series is to characterize the clinical presentation, radiology, pathology, and surgical outcomes associated with foot glomus tumors. We reviewed our pathology database for patients with foot glomus tumors diagnosed between 1995 and 2013. Medical records including physician notes, pathology, and radiology were reviewed. Eleven patients had foot glomus tumors excised at our institution during the study period. The mean age was 45.4 (range = 28-60) years. One patient was lost to follow-up. Mean follow-up for the remaining 10 patients was 44.7 (range = 3-142) months. Ten tumors were located in the subungual region, while 1 was located in the plantar pulp of the distal phalanx. All patients presented with pain. Point tenderness, cold hypersensitivity, and nail abnormalities were variably documented but frequently present. Four patients had had prior surgery for an ingrown toenail prior to presentation at our institution. Six patients had preoperative magnetic resonance imaging studies, which were diagnostic of glomus tumor in all cases except one. Radiographs failed to provide diagnosis in all 8 patients for whom they were obtained. Postoperatively, all patients had complete symptom relief with no recurrences.In conclusion, this case series demonstrates that foot glomus tumors frequently present with classic symptoms including pain, point tenderness, and cold hypersensitivity. When clinically suspected, magnetic resonance imaging should be obtained. Marginal excision results in symptom relief and cure.

LEVEL OF EVIDENCE

Therapeutic, Level IV: Case series.