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

Subungual glomus tumor

Subungual glomus tumors arise from the glomus body of the digits. They are rare and benign and often in a single location. Their diagnosis relies on the typical clinical triad of symptoms and on imaging findings, mainly magnetic resonance imaging with gadolinium injection. Subungual tumors treatment is complete resection, essential for cure. The different surgical techniques aim to: a painless digit with normal range of motion and sensitivity, without nail deformity after tumour resection, and to recurrence prevention. They vary according to tumor location. Classic surgical approaches are: the nail unit sparing ones (para-ungual, lateral subperiosteal, periungual), and the nail unit non-sparing ones (all transungual approaches with nail bed splitting). In this paper, we review the literature for the different approaches describing the advantages and drawbacks of each of them. We also describe the author's preferred subperiosteal "shark mouth" flap containing the nail plate and the nail bed as a single unit. It can be performed whether the tumor is located centrally, peripherally, or under the germinal matrix with very satisfactory outcomes.

Ultrasound Features of Onychopapilloma at High-Frequency and Ultra-High Frequency

OBJECTIVE

This study aimed to identify the sonographic features of pathologically confirmed onychopapilloma cases.

METHODS

High-frequency up to 24 MHz and ultra-high frequency-ultrasound up to 71 MHz examinations were performed and correlated with their clinical and pathologic presentations.

RESULTS

Twenty-two cases met the criteria. Clinical presentations revealed longitudinal erythronychia in 63.3% of cases. The ultrasound examinations identified a hypoechoic band in the nail bed (86.3%), nail plate abnormalities including upward displacement (68.2%) and thickening (68.1%), focal hyperechoic focal spots on the nail plate (50%) and irregularities of the ventral plate (33.3%). Color Doppler imaging showed no hypervascularity of the nail bed in all studies. These findings correlate with histological characteristics of onychopapilloma, including nail bed acanthosis, papillomatosis, and layered hyperkeratosis. Recurrence occurred in two cases after surgery, with tumors showing proximal extension in the matrix region on ultrasound not evident during clinical examination.

CONCLUSION

High-frequency and ultra-high-frequency can provide anatomical information in onychopapilloma that could enhance understanding and management.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Practical applications of ultrasound in dermatology

Ultrasound has evolved in dermatology from an experimental phase to a daily practice imaging technique. Its several advantages include its safety, good balance between penetration and resolution, high definition, and the detection of blood flow in real time. Its applications are growing and include the support of the diagnosis and extent in all axes, including depth, vascularity patterns, staging, and follow up of multiple cutaneous diseases-benign cutaneous tumors, vascular anomalies, nail lesions, skin cancer, inflammatory cutaneous diseases, and aesthetics complications.

Extradigital Glomus Tumor of the Forearm Identified During Neuromuscular Ultrasound: A Case Report

Glomus tumors are rare benign soft tissue tumors that arise from the glomus body. They typically develop in the subungual region but may develop extradigitally anywhere, in the upper or lower limbs. Extradigital glomus tumors can be misdiagnosed for years because of their atypical position and presentation. Being aware of an extradigital glomus tumor is important because they can be encountered during imaging studies and may be the cause of the patient’s symptoms. This report presents a case of an extradigital glomus tumor, of the forearm, diagnosed during neuromuscular sonography, in a patient with chronic intractable neuropathic-like pain, along the medial side of the left forearm. Sonographic imaging of the nerves, muscles, and tendons did not reveal any abnormalities. However, meticulous imaging of all tissue layers detected a subcutaneous vascular nodule. Subsequent excision biopsy and histopathologic assessment revealed a glomus tumor. After surgery, the patient experienced dramatic relief of pain. This case report highlights the importance of careful sonographic examination of all the tissues, including skin and subcutaneous tissue layers, to avoid missing non-neuromuscular pathologies that impact patient’s management.

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.

Diagnosis of Subungual Glomus Tumors with 18 MHz Ultrasound and CDFI

To evaluate the imaging features of subungual glomus tumors using 18 MHz high-frequency ultrasound with CDFI (Color Doppler Flow Imaging). 20 patients treated by surgical resection and examined by ultrasound between January 2008 and December 2019. All eligible cases are divided into two groups: Group A used the probe frequency of 9–14 MHz from January 2008 to December 2014, and Group B used the probe frequency of 18 MHz from January 2015 to December 2019. Patient demographics, clinical records, pathologic specimens and sonography features were reviewed. 50% of tumors in Group A and 100% of tumors in Group B showed clear boundary and regular shape. Blood flow signals were identified inside 50% tumors in Group A (3 in 6), all 14 cases with blood flow signals detected in Group B (14 in 14,100%). 2 cases were misdiagnosed and 1 case escaped diagnosis in Group A, no case was misdiagnosed in Group B. The accuracy of diagnosis rate of Group B is significantly higher than that of Group A. 18-MHz ultrasound combined with CDFI may be a practical useful tool for detecting subungual glomus tumors. More importantly 18-MHz ultrasound can obviously improve the diagnostic accuracy.

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.

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.

Glomus tumor of the fingertips: A frequently missed diagnosis

Background:

Glomus tumors present as painful lesions, most commonly in the fingertips. These can present to outpatient clinics of multiple specialties.

Materials and Methods:

Retrospective review was performed of 37 patients diagnosed as having glomus tumor in the thumb or fingertips over a 10-year period. The data collected included demographics, presenting symptoms, duration, previous treatment history, physical examination, treatment, and recurrence. The data were presented by means of descriptive statistics.

Results:

The mean duration of symptoms before presentation was 3.8 years (range 2 to 12 years). The mean age at presentation was 38 years (range 16 to 62 years), and female to male ratio was 21:16. Twenty-two patients had left-hand involvement; thumb 8, index finger 5, middle finger 5, ring finger 14, and little finger 5. Clinical and radiological assessments were made preoperatively. At presentation, 18 cases had nail changes, whereas 19 had no obvious nail changes – out of these, 4 had pulp involvement. The lesion involved the subungual region in 33 cases. The mean size of the lesion was 3.8 mm (range 2 to 10 mm). Thirty-six patients were found to have histopathologically proven glomus tumors, whereas in one no specific lesion was found on histopathological examination; this patient returned with recurrence of symptoms at 2-month follow-up. There was no other patient experienced recurrence of symptoms.

Conclusion:

Early diagnosis of glomus tumors is important to avoid lengthy treatment delays, chronic pain, disuse syndromes, and psychiatric misdiagnoses.

Sonography of Dermatologic Emergencies

Dermatologic conditions may be the subjects of potential emergency consultations, and the knowledge of their sonographic appearance can facilitate an early diagnosis and management. In this pictorial essay, the sonographic dermatologic anatomy, technique, and conditions that can be supported by a prompt sonographic diagnosis are reviewed. The sonographic signs that may help diagnose these entities are discussed with a practical approach.

Sonographic diagnosis of a glomus tumor of the thigh

Extradigital glomus tumors are a very rare entity. Here, we report a rare case of a glomus tumor in an atypical anatomic site: the thigh. The clinical features together with the results of MRI, and sonography and Doppler sonographic imaging helped to distinguish glomus tumor of the thigh from other soft tissue neoplasms. The tumor arising from the thigh was excised, and following surgery, the patient was symptom free without evidence of complications or recurrence. There have only been a few previously reported cases describing the use of Doppler sonography in the evaluation of extradigital glomus tumors. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:50-52, 2017.

Color Doppler Sonography of Extradigital Glomus Tumors

We retrospectively collected cases of surgically proven extradigital glomus tumor (EDGT) and reviewed their demographic, clinical, and sonography features. A total of 18 single, subcutaneous EDGTs were gathered. All but one were located in the extremities. EDGTs typically appear as a small, hypoechoic, homogeneous, or slightly inhomogeneous, well-delimited nodule, disposed horizontally and painful under probe pressure. Intranodular vascularization is always present. Feeding artery and efferent vein are typical but inconstant findings.

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.

Coexistence of glomangioma and yolk sac tumour in a child: a case report

Glomus tumours (GTs) primarily arise from glomus bodies that are located in the dermis layer of skin. However, they can be encountered ectopically in most parts of the body. As a result of researches done in a 17-month-old male patient who prssented to us with complaint of an increasingly growing swelling, he was diagnosed with a yolk sac tumour. Chemotherapy was started and then, he was operated. GT was found inside the tumoural mass. Our patient, who is the first case according to our knowledge, where the concurrence of yolk sac and glomus tumours was reported, has been discussed in the light of literature.

Subungual schwannoma with clinical, sonographic, and histologic correlation

We show an unusual presentation of a schwannoma that was located in the ungual bed of the left great toe. The clinical, color Doppler ultrasound imaging, and histologic findings are shown to illustrate the case. This type of neurogenic tumor and the ultrasound presurgical imaging support should be considered when dealing with subungual tumors of the foot.

Common applications of dermatologic sonography

In recent years, there has been growing use of sonography in the dermatologic field. Thus, this review analyzes the most common dermatologic applications of sonography with some technical considerations for performing this type of examination. Moreover, the sonographic findings in common benign and malignant skin tumors, inflammatory dermatologic diseases, and ungual and cosmetic conditions, among others, are considered. Thus, this noninvasive technique may be a potent adjunctive tool in the diagnosis and management of dermatologic conditions in daily practice, delivering critical information otherwise unavailable to the clinical naked eye.

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.

Optical coherence tomography for imaging of skin and skin diseases

Optical coherence tomography (OCT) is an emerging imaging technology based on light reflection. It provides real-time images with up to 2-mm penetration into the skin and a resolution of approximately 10 microm. It is routinely used in ophthalmology. The normal skin and its appendages have been studied, as have many diseases. The method can provide accurate measures of epidermal and nail changes in normal tissue. Skin cancer and other tumors, as well as inflammatory diseases, have been studied and good agreement found between OCT images and histopathological architecture. OCT also allows noninvasive monitoring of morphologic changes in skin diseases and may have a particular role in the monitoring of medical treatment of nonmelanoma skin cancer. The technology is however still evolving and continued technological development will necessitate an ongoing evaluation of its diagnostic accuracy. Several technical solutions are being pursued to further improve the quality of the images and the data provided, and OCT is being integrated in multimodal imaging devices that would potentially be able to provide a quantum leap to the imaging of skin in vivo.

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.