Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 115-117

Subungal Glomus Tumor: Rare but Real


Department of Vascular Surgery, Yashoda Super Speciality Hospital, Somajiguda, Hyderabad, Telangana, India

Date of Web Publication8-Oct-2015

Correspondence Address:
Devender Singh
Department of Vascular Surgery, Yashoda Super Speciality Hospital, Somajiguda, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0820.166932

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  Abstract 

Glomus tumor is a rare benign neoplasm that arises from the neuroarterial structure called a glomus body and accounts for 1–2% of soft tissue tumors in the hand. The patients with glomus tumor will present with excruciating pain, disproportionate to their signs, as the majority of the time there are no visible manifestations. Hence, these patients are treated with all the specialties (including psychiatrists) with different combinations of analgesics, anxiolytics, and antidepressants. A strong clinical suspicion and a properly planned surgery remain the treatment. We present a case of a 36-year-old male suffering from excruciating pain, demanding to the extent of amputation, was diagnosed clinically based on his history and treated for subungal glomus tumor of a left middle finger.

Keywords: Glomus tumor, magnetic resonance imaging, nail bed, surgical excision


How to cite this article:
Singh D. Subungal Glomus Tumor: Rare but Real. Indian J Vasc Endovasc Surg 2015;2:115-7

How to cite this URL:
Singh D. Subungal Glomus Tumor: Rare but Real. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2019 Dec 8];2:115-7. Available from: http://www.indjvascsurg.org/text.asp?2015/2/3/115/166932


  Introduction Top


Glomus tumor is a rare tumor arising from a neuromyoarterial glomus,[1] which is an arteriovenous anastomosis functioning without an intermediary capillary bed. Normal glomus bodies aid in the regulation of skin circulation and to be highly concentrated in the finger tips, particularly beneath the nail. The treatment of this lesion is complete surgical excision. We treated a 36-year-old male patient who was suffering from obscure pain due to the subungal glomus tumor of her left middle finger.


  Case Report Top


A 36-year-old male presented with 4 years history of excruciating pain in the left middle finger aggravated during winter months and by working with cold water. The severity of symptoms made him to demand for an amputation. There was no history of trauma nor was there any other past medical or surgical history of significance. On examination, there was no clue of any lesion in the finger [Figure 1], however, he was pointing over a spot which was exquisitely tender. Hildreth's and Love's signs were positive. Plain films of the affected thumb did not reveal any abnormality. Magnetic resonance imaging (MRI) of the affected thumb was planned as clinically the lesion was not appreciated. High resolution MRI (HR-MRI) showed high signal intensity area under the nail bed. The patient was operated upon under local anesthesia (digital block) with 1% xylocaine with proximal tourniquet control. Through transungual approach, 0.5 cm × 0.5 cm shiny, pinkish, encapsulated lesion was found arising from nail bed [Figure 2], eroding the bone [Figure 3], [Figure 4], [Figure 5]. This lesion was excised in toto. The histopathological analysis of the lesion confirmed the diagnosis of benign glomus tumor. The patient had an uneventful postoperative period and was symptom free and satisfied at 6 months follow-up.
Figure 1: Painful site with no obvious lesion on examination

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Figure 2: Magnetic resonance imaging showing a lesion

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Figure 3: Glomus tumor on exploration

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Figure 4: Nail bed with glomus tumor

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Figure 5: Glomus tumor in total

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  Discussion Top


Glomus tumor is rare and benign vascular tumor [1] and constitutes 1–2% of the soft-tissue tumors in the hand. In 1812, glomus tumor was described by Wood as a painful subcutaneous “tubercle."[2] Fifty percent of these occur under the fingernail, usually to people between the ages of 30 and 50 years, twice as often to women as men.[1],[2],[3]

Multiple glomus tumors are present in 2.3% of cases.[4] The normal glomus unit is a neuromyoarterial apparatus that functions to regulate skin circulation and is found subungually, on the fingertip pulp, on the base of the foot, and the rest of body in descending order. Glomus tumor arises from the arterial portion of the glomus body, or the Sucquet-Hoyer canal of this apparatus. The initiating event for glomus cell proliferation is unknown. Some authors have postulated that trauma induces solitary subungual glomus tumors, although this theory is not well studied. Other synonyms for glomus tumors include glomangioma, a tumor of the neuromyoarterial glomus, angioneuromyoma, and Popoff tumor.[5]

Clinically, glomus tumors are characterized by a triad of sensitivity to cold, localized tenderness, and severe and intermittent pain.[6] The pain can be excruciating and is described as a burning or bursting. The exact cause of the pain is unknown, but nerve fibers containing the pain neurotransmitter substanceP have been identified in the tumor.[7] Diagnosis of glomus tumors is primarily clinical. Several clinical tests are useful for diagnosing glomus tumors. Love [8] reported that localization of the tenderness to an area and the size of a pinhead were suggestive of glomus tumor. For a positive Love's pin test, the patient should experience severe pain when the skin overlying the tumor is pressed with a ballpoint pen, end of a paperclip, pinhead or K-wire. The cold-sensitivity test is positive when immersing the hand in cold water for 60 s elicits severe pain in and around the lesion. In addition, there should be a history of cold weather aggravating the symptoms was evident in our patient. Hildreth's test is another reliable clinical sign for the diagnosis of glomus tumors.[9] This test is performed by elevating the patients' arm to exsanguinate it. A tourniquet is inflated to 250 mm Hg and if the test is positive then there is a reduction in pain and tenderness. A test is also positive when releasing the cuff causes a sudden onset of pain and tenderness in the area of the tumor.

Plain films generally are not helpful in visualizing this tumor though in longstanding cases may reveal a concave contour deformity of the phalanx or a focal, well-defined cortical lucency.[10] Computed tomography scan imaging does not add anything valuable for diagnosis and ultrasound in expert hands can identify these lesions as solid hypoechoic foci.[11]

In addition, the localized and enlarged blood vessels encased by the tumor may be visualized on color Doppler. However, HR-MRI has been found to be a specific and sensitive tool for diagnosis of glomus tumors and can detect lesions as small as only 1 mm.[8] Most glomus tumors show high signal intensity on T2-weighted spin-echo MRIs and strong enhancement after injection of a gadolinium compound.[12],[13] Subungual glomus tumors are treated by surgical excision. The tumor may be approached by the subungual or lateral approach and in either method, the nail plate is reflected and the tumor is exposed and excised along with the capsule. The incidence of tumor recurrence after surgical excision ranges from 5% to 50% depending primarily on the surgical technique.[14]

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Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Theumann NH, Goettmann S, Le Viet D, Resnick D, Chung CB, Bittoun J, et al. Recurrent glomus tumors of fingertips: MR imaging evaluation. Radiology 2002;223:143-51.  Back to cited text no. 1
    
2.
Wood W. On painful subcutaneous tubercle. Edinb Med J 1812;8:283-91.  Back to cited text no. 2
    
3.
Van Ruyssevelt CE, Vranckx P. Subungual glomus tumor: Emphasis on MR angiography. AJR Am J Roentgenol 2004;182:263-4.  Back to cited text no. 3
    
4.
Heys SD, Brittenden J, Atkinson P, Eremin O. Glomus tumour: An analysis of 43 patients and review of the literature. Br J Surg 1992;79:345-7.  Back to cited text no. 4
    
5.
Fornage BD. Glomus tumors in the fingers: Diagnosis with US. Radiology 1988;167:183-5.  Back to cited text no. 5
    
6.
Vandevender DK, Daley RA. Benign and malignant vascular tumors of the upper extremity. Hand Clin 1995;11:161-81.  Back to cited text no. 6
    
7.
Kishimoto S, Nagatani H, Miyashita A, Kobayashi K. Immunohistochemical demonstration of substance P-containing nerve fibres in glomus tumours. Br J Dermatol 1985;113:213-8.  Back to cited text no. 7
[PUBMED]    
8.
Love JG. Glomus tumors: Diagnosis and treatment. Proc Staff Meet Mayo Clin 1944;19:113-6.  Back to cited text no. 8
    
9.
Giele H. Hildreth's test is a reliable clinical sign for the diagnosis of glomus tumours. J Hand Surg Br 2002;27:157-8.  Back to cited text no. 9
    
10.
Murphey MD, Fairbairn KJ, Parman LM, Baxter KG, Parsa MB, Smith WS. From the archives of the AFIP. Musculoskeletal angiomatous lesions: Radiologic-pathologic correlation. Radiographics 1995;15:893-917.  Back to cited text no. 10
    
11.
Wortsman X, Jemec GB. Ultrasound imaging of nails. Dermatol Clin 2006;24:323-8.  Back to cited text no. 11
    
12.
Drapé JL, Idy-Peretti I, Goettmann S, Wolfram-Gabel R, Dion E, Grossin M, et al. Subungual glomus tumors: Evaluation with MR imaging. Radiology 1995;195:507-15.  Back to cited text no. 12
    
13.
Hou SM, Shih TT, Lin MC. Magnetic resonance imaging of an obscure glomus tumour in the fingertip. J Hand Surg Br 1993;18:482-3.  Back to cited text no. 13
    
14.
Van Geertruyden J, Lorea P, Goldschmidt D, de Fontaine S, Schuind F, Kinnen L, et al. Glomus tumours of the hand. A retrospective study of 51 cases. J Hand Surg Br 1996;21:257-60.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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