Transungual surgical excision of subungual glomus tumour

Glomus Tumor of the Left Second Toe Distal Phalanx: A Case Report and Review of Literature

Introduction

Glomus tumors are rare, benign neoplasms that originate from glomus bodies. While usually occurring in the subungual regions of the fingers, glomus tumors are seldom found in the foot, although rare reports have been made of glomus tumors in the hallux and even fewer in the lesser toes. We describe a reported case of a glomus tumor occurring in the distal phalanx of the left second toe that was initially missed on imaging studies, resulting in delayed diagnosis and surgical treatment. To the best of our knowledge, this represents one of the first few cases of glomus tumor reported in the lesser toes.

Case Report

A 34-year-old Chinese female presented with pain in the left second toe occurring for several years. Initial assessment and radiological investigations came back negative for abnormalities, resulting in delayed treatment. Upon second opinion of the MRI scans, a 0.2 × 0.2 × 0.2 cm well-defined round enhancing high T2-weighted signal focus within the germinal matrix of the left second toe subungual region was found, suggestive of a glomus tumor. Surgical exploration was offered, which found a skin-colored lesion, which was resected using a transungual approach. The final histology of the excised mass showed perivascular proliferation of uniform cells which contained round to ovoid nucleus with small nucleolus and pale eosinophilic cytoplasm, confirming glomus tumor.

Conclusion

Glomus tumors are rarely found in the foot, with even fewer reports in the lesser toes. Their rare occurrence in these regions reduces diagnostic suspicion for these tumors, delaying diagnosis and treatment for patients. This case report highlights the difficulty in diagnosing glomus tumors, even with adequate radiological investigations, and showcases the need for careful scrutinization of imaging. As this presentation is extremely uncommon, we hope that this case report increases suspicion of glomus tumors as a differential diagnosis for toe pain to ensure early treatment and alleviation of symptoms for patients.

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).

Glomus tumor causing chronic finger pain: ischemia test is a reliable clinical sign for the diagnosis. Case report and review of literature

Glomus tumors are a rare, benign neoplasm arising from the neuroarterial structure known as the glomus body, which is a specialized arteriovenous shunt involved in temperature regulation. They account for less than 2% of soft tissue tumors and between 1% and 4.5% of tumors in the hand.. Despite their first descriptions appearing almost 100 years ago, late and missed diagnoses are common, leading to significant suffering. The classic diagnostic triad includes spontaneous pain, a sensation of pressure and tenderness, and cold hypersensitivity. Magnetic resonance imaging remains the most useful imaging modality. The abolition of pain after inflating a blood pressure cuff above the systolic blood pressure level (ischemia test) is highly diagnostic.Therefore, we suggest the routine use of this simple test in cases of upper limb pain of unclear etiology . Surgical excision is the treatment of choice and is curative.

Modified nail folding approach: A novel strategy for the treatment of subungual glomus tumors-A case series study

Key Clinical Message

The modified nail folding approach, a new surgical technique, has been shown to be safe and effective for the treatment of subungual glomus tumors, providing clinicians with a new treatment option for patients with this condition.

Abstract

Glomus tumors (GTs) are rare benign tumors that originate from the glomus body in the skin of the fingertips, toes, and nail beds. GTs are more prevalent in women than in men and can occur sporadically or as part of an inherited condition known as multiple GTs. The exact cause of GTs is unknown, but it is believed that mutations in the cells of the glomus body contribute to their development. In this study, we present the efficacy of a novel surgical technique called the modified nail folding approach for treating subungual GTs. We report a case series involving 17 patients who underwent the nail folding approach for surgical removal of subungual GTs. The primary objective of this article is to provide evidence supporting the safety and effectiveness of this technique. Additionally, we aim to introduce clinicians to a new, secure, and efficient treatment option for patients with subungual GTs.

Diagnosis and surgical approach in treating glomus tumor distal phalanx left middle finger: A case report

INTRODUCTION AND IMPORTANCE

Glomus tumors are rare mesenchymal neoplasms. These tumors originate from the glomus bodies and are commonly found in the fingertips, especially in the subungual location. The cause of this tumor is unknown. Clinically, the symptoms are non-specific and often not identified on physical examination and radiologically accompanied by rare cases, making it difficult to diagnose a glomus tumor.

CASE PRESENTATION

Current report present a case of pain at the tip of the middle finger of the left hand in a woman for six years and worsening in the last two years. The patient has visited several doctors with analgesic therapy, but the complaints have not improved. A bluish nail was found on physical examination, and a clinical study with the Love's pin test and the Hildreth test had positive results. Radiographic examination showed destruction with cortical thinning of the medial aspect of the distal phalanx of the left middle finger, and MRI showed a lesion with an erosion of the distal middle finger. In this case, complete surgical excision and biopsy were performed using a transungual surgical approach. The sample was sent for microscopic examination, showing a glomus tumor.

CLINICAL DISCUSSION

Cases with clinical symptoms of intense paroxysmal pain, exquisite point tenderness, and sensitivity to cold allow a clinical diagnosis in 90 % of cases. On clinical examinations such as Love's pin test, Hildreth's test, cold sensitivity test, and trans-illumination test with positive results and confirmed by MRI or ultrasound, the diagnosis of glomus tumor can be established.

CONCLUSION

This case shows a glomus tumor in the distal phalanges of the middle finger of the left hand-diagnosis enforcement through detailed history taking and physical examination, confirmed by MRI and microscopic examination. Complete surgical excision is an effective treatment. In this case, using a transungual surgical approach based on preoperative MRI, the subungual lesion was found to provide the best exposure.

A Curious Case of Paroxysmal Painful Thumb: Glomus Tumor Re-visited

Glomus tumor is a rare and benign vascular hamartoma originating from the neuro-myo-arterial apparatus of the glomus body in the reticular dermis. Most commonly, it presents as a solitary subungual lesion which is often painful and triggered by changes in temperature and pressure on the affected digit. However, multiple glomus tumors both digitally and elsewhere on the body which may or may not be painful are also known to occur. Due to its cryptic location and varied presentation, there is an invariable delay in the diagnosis and management of this condition. We report a case of glomus tumor in a 28-year-old woman presenting with paroxysmal painful lesion over her right thumb for 5 years.

A Rare Case of Glomus Tumor on the Mucosal Surface of Lower Lip

Glomus tumors are mesenchymal neoplasms derived from glomus bodies with rare presentations in the oral cavity. Glomus tumors present as a purple or pink vascular nodule or papule, sized <1 cm, and imitate vascular neoplasms such as hemangiopericytoma or hemangioma. Glomus tumors represent less than 2% of all benign soft tissue tumors. Only 27 cases of benign glomus tumors with oral cavity involvement have been reported to date. The most-reported oral tumors involved the lips (54.2%), followed by hard palate, gingiva, tongue, and buccal mucosa. The mean age of presentation of the labial glomus tumors is 48.7 years, with no gender predilection, in contrast to the subungual site, which occurs more in females. The etiology of the glomus tumors remains unknown. Subungual glomus tumors present as stabbing pain, cold intolerance, and tenderness of the fingertips, whereas labial glomus tumors mostly present as a painless, small, and slow-growing lesion. Treatment is surgical resection of the tumor. The recurrence rate of labial glomus tumors is unclear. In this article, we present the case of a 62-year-old man with a 2-month history of painless, soft lump on the mucosal surface of the lower left lip. Excisional resection of the tumor was performed in the clinic, and the histopathologic finding was consistent with solid glomus tumor. At 1 year follow-up there was no recurrence.

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.

Nail Biopsy: A User's Manual

Nail biopsy is a procedure not routinely resorted to; but when indicated, it is often the only clue left for diagnosis. At such times, it pays to be conversant with it. It is an investigation that not only provides etiologic, diagnostic, and prognostic information but also aids in understanding the pathogenesis of nail diseases. It can be of therapeutic value, especially with respect to nail tumors. This article compiles the procedural techniques for nail biopsy of various types and attempts to summarize the evidence available in the literature. The objective of nail biopsy is to clinch a precise diagnosis of nail pathology with a simple and safe surgical procedure, avoiding pain or permanent nail damage. Patient selection is of utmost importance, wherein, the patient does not have typical skin lesions, yields inadequate information on routine nail investigations, and has no peripheral vascular compromise. The patient needs to be explained about the risks associated, the expected functional handicap, the time required for regrowth, a possibility of permanent nail dystrophy, and a possibility of not achieving a diagnosis even after the biopsy. Techniques and types of various nail biopsies are being discussed in this article. The specimen could be collected as an excision biopsy, punch biopsy, shave biopsy, or longitudinal biopsy. The trick lies in choosing the appropriate area for biopsy. Various biopsy types discussed in this article include nail plate biopsy (easiest and least scarring); nail bed biopsy (elliptical excision or punch); nail matrix biopsy (elliptical excision, punch excision (≤3 mm) or tangential/shave excision); and nail fold biopsy. Complications reported along with means to minimize them are also discussed.

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.

[Solitary subungual glomangioma]

BACKGROUND

Glomangiomas are benign vascular tumours. They are usually multiple, painless and extradigital. Herein we report a case of a solitary subungual glomangioma.

PATIENTS AND METHODS

This 65-year-old woman presented with a history of bluish, asymptomatic, subungual lesions located in the lunula of her right thumb. Surgical exploration by a transungual approach showed a large bluish, well-circumscribed tumour, which was completely excised. Histological examination revealed numerous dilated blood vessels surrounded by aggregates of glomus cells, which was consistent with the diagnosis of glomangioma.

DISCUSSION

Glomus tumours are benign tumours arising from glomus cells. Histopathologically, based on the predominant tissue type present, glomus tumours are classified as solid glomus tumours, glomangiomas or glomangiomyomas. The classical form usually consists of a painful erythematous nodule with exaggerated sensitivity to cold and pressure. The nails are frequently involved, with two sites of predilection: the matrix and the nail bed. Vascular forms of glomus tumours or glomangiomas have a different clinical presentation and are usually multifocal, bluish, painless and extradigital. Diagnosis is frequently based on histological examination. Our observation raises the question of differential diagnosis with regard to matrix melanocytic tumours (blue nevi or melanomas).

CONCLUSION

We report the case of a solitary subungual glomangioma. Histological examination is necessary to rule out a clinically indistinguishable benign or malignant melanocytic tumour.