Archives of International Surgery

CASE SERIES
Year
: 2020  |  Volume : 10  |  Issue : 2  |  Page : 52--56

Glomus tumour: A review of clinical presentation and treatment


Ibad Sha1, Ajin Edwin1, Namitha Shah2, Roshna Cini3,  
1 Department of Orthopedics, Government of Medical College, Thiruvananthapuram, Kerala, India
2 Department of Radiology; Department of Radiodiagnosis, KIMS, Thiruvananthapuram, Kerala, India
3 Department of Radiology, Government of Medical College, Kozhikode, Kerala, India

Correspondence Address:
Dr. Ibad Sha
Department of Orthopedics, Government of Medical College, Thiruvananthapuram - 695 011, Kerala
India

Abstract

Glomus tumors are perivascular hamartomas originating from glomus apparatus which are rare in occurrence and have a higher predilection for the subungual region of the hand. We retrospectively analyzed the management and outcome of patients with subungual glomus tumor treated over a period of 5 years from January 2013 to December 2018. Clinical evaluation included Love's test, Hildreth's test, and cold sensitivity tests. X-ray and MRI were done for all patients. Transungual approach was used in the treatment of all the patients. Total of seven cases were included in the study (6 females and 1 male). Mean age was 30.4 years with a range from 21 to 42 years. Average duration of complaints was 1.6 years ranging 1-3 years. Bone involvement was detected only in one case. Average size of the lesion was 2.7 mm ranging from 1.8 to 4 mm. Post operatively there was no nail deformity except in one patient.



How to cite this article:
Sha I, Edwin A, Shah N, Cini R. Glomus tumour: A review of clinical presentation and treatment.Arch Int Surg 2020;10:52-56


How to cite this URL:
Sha I, Edwin A, Shah N, Cini R. Glomus tumour: A review of clinical presentation and treatment. Arch Int Surg [serial online] 2020 [cited 2021 Jun 16 ];10:52-56
Available from: https://www.archintsurg.org/text.asp?2020/10/2/52/316489


Full Text



 Introduction



Glomus tumors are perivascular hamartomas originating from the glomus apparatus.[1] The glomus body/glomus apparatus are chemoreceptors that regulate blood flow in capillaries in response to changes in temperature.[1],[2] They are composed of afferent arterioles, arteriovenous anastomosis, collecting veins, and neurovascular reticulum.[3] The glomus tumors are rare in occurrence and have a higher predilection for the subungual region of the hand which can be attributed to a high concentration of glomus bodies in the digits, palms, and soles.[3],[4] A total of 65% of glomus tumors are localized in the subungual region and up to 75% occur in the hand.[4],[5] These tumors are also reported in visceral locations including the lung, stomach, pancreas, liver, gastrointestinal, and genitourinary tract.[5] Although glomus tumors are benign, they can rarely be malignant when presenting as large, profound, and visceral lesions.[3]

Classical clinical triad (Carroll triad) of temperature sensitivity, severe pain, and localized tenderness are seen in 63–100% of cases.[6] Because of the rarity and varying presentations, glomus tumors often pose diagnostic challenges, with patients carrying on with complaints for many months before proper identification and treatment. Magnetic resonance imaging (MRI) with contrast helps in the identification of lesions, especially when vascular and more than 2 mm.[7] Excision of the lesion completely will prevent recurrence and relieve pain.[5],[8] Post-operative nail deformity is one complication to watch out for. Diagnostic confirmation is through histopathology, which demonstrates capillaries lined by glomus cells with immunoreactivity to smooth muscle actin and CD34.[9] We hereby report a series of seven cases of subungual glomus tumors treated in tertiary care government hospital over a period of five years and our experience in their treatment. Our analysis of data includes tumor presentation, investigations, treatment methods, and outcomes.

 Patients and Methods



We retrospectively analyzed patients diagnosed and treated as a subungual glomus tumor over a period of 5 years (January 2013–December 2018). We analyzed their clinical data, imaging, and treatment details. Clinical evaluation included Love's test, Hildreth's test, and cold sensitivity tests where Love's test was done on all patients while Hildreth's sign and cold sensitivity test were done only on some [Figure 1]. X-ray and MRI were done for all patients. Transungual approach was used in all the patients. Follow-up was done at intervals of 2 weeks, 3 months, 6 months, and 1 year.{Figure 1}

 Surgical Technique



All patients were operated under the digital block with 1% lignocaine without adrenaline. Finger tourniquet made of rubber glove was used after finger exsanguination to achieve a bloodless field. The surgical site was prepared antiseptically. Transungual approach was used [Figure 2]. The incision was put along the lateral aspect of the proximal nail fold and was lifted proximally. Nail plate was then lifted distally exposing the nail bed. Transungual incision was put on the nail plate when lesions are midline. Nail bed was incised sharply corresponding to the site of lesion and en bloc removal of the tumor was done [Figure 3] and [Figure 4]. Curettage of bone was done only in case of deep-seated lesions with or without bony erosion as a precaution to avoid recurrence. The nail bed was sutured with 6–0 vicryl and the lifted nail was replaced over the nail bed and proximal nail fold sutured with 3–0 monocryl. The dressing was done using antibiotic ointment and gauze. An alternate day dressing was done until the wound was dry, after which it was kept open.{Figure 2}{Figure 3}{Figure 4}

 Results



A total of seven cases was included in the study (6 females and 1 male). The mean age was 30.4 years ranging from 21 to 42 years [Table 1]. All cases presented with sharp pain and local tenderness. The average duration of complaints was 1.6 years (ranging 1–3 years). Color change was noted in two patients and in both these cases, the size of the lesion was more than 3 mm. MRI evaluation contributed to diagnosis as well as preoperative localization and assessment of lesion size [Figure 5]. Bone involvement was detected only in one case. The average size of the lesion was 2.7 mm ranging from 1.8 to 4 mm. Intraoperative localization was done by the pre-operative marking on the nail corresponding to the site of maximum tenderness and referencing with MRI images. All specimens were sent for histopathological evaluation for confirmation of diagnosis [Figure 6]. The majority (six out of 7 patients) had no nail deformity postoperatively [Figure 7]. All patients were followed up for 1 year and none of them had a recurrence of pain or related symptoms at 1-year follow-up.{Figure 5}{Figure 6}{Figure 7}{Table 1}

 Discussion



Glomus tumors are rare, benign neoplasm first described by Wood in 1812.[6],[10] Barre and Masson was the first to describe the histology of glomus tumor in 1924.[10] They originate from the glomus apparatus/glomus body which is a normal subcutaneous (stratum reticularis) structure functioning as a chemoreceptor.[9],[11] Structure of the glomus body includes an afferent arteriole, an anastomotic Suquet-Hoyer canal, an efferent venule, actin-containing glomus cells, the intraglomerular reticulum, and a capsular part.[12] The tumors develop as a result of hyperplasia of one or more of the normal components of the glomus body.[4],[7],[13] They have a higher predilection to areas rich in glomus bodies like subungual regions of digits or the deep dermis of the palm, wrist, forearm, and foot.[5] Literature reports of tumors occurring in other sites like the upper lip, the base of the skull, nasal cavity, tympana, jugular vein, neck, dorsal and lumbar vertebrae, coccyx, have also been documented.[14]

Glomus tumors account for 1–5% of all soft tissue tumors of the hand.[1] The subungual tumors are more common in women while in other locations male-to-female ratio is variable.[4] The most common age of presentation is around 30 yrs even though cases have been reported in all age groups but its occurrence in the pediatric age group is exceedingly rare.[15] Clinically the classic triad of symptoms are (1) hypersensitivity to cold, (2) paroxysmal pain, and (3) pinpoint pain in the finger and are seen in 63–100%.[1],[14] Other features like bluish discoloration and nail deformity have been reported in 28% and 33% of patients, respectively.[4],[6] In our series, all patients had point tenderness while only four out seven had hypersensitivity to cold. Bluish discoloration was noted only in two cases, both of them had tumor of size more than 3 mm. The average duration of presentation in our series was 1.7 years, a little longer compared to another series where the average time of presentation was 7 months. The longer duration for presentation can be attributed to misdiagnosis by earlier physicians or late referral to specialists.

Clinical tests described for glomus tumors include Love's test, Hildreth sign, and Cold-sensitivity test.[2],[16] Positive Love's test is one where localization of tenderness with a pinhead or similar sized object is possible and it has been described as a 100% sensitive test.[17] In Hildreth sign the patient's arm is exsanguinated by elevating followed by inflation of tourniquet to 250 mm Hg and the tumor is then palpated, pain and tenderness should be reduced. On releasing the cuff if there is a sudden onset of pain and tenderness, the test is considered positive. A study by Giele et al. reported a sensitivity of 92% and specificity of 91% for Hildreth sign in glomus tumors.[2] Cold sensitivity test is another test with a reported sensitivity of 84%. The test is positive if severe pain in and around the lesion develops on immersing the hand in cold water. According to Bhaskaranand and Navadgi's series, Love's test was 100% sensitive while Hildreth's sign was 71.4% sensitive.[16] In our series, Love's test was positive in all the patients. Hildreth sign was evaluated only in three patients and the sign was negative in one while positive in the remaining two. Hypersensitivity to cold was noted in only four patients out seven.

Radiologic evaluation in the glomus tumor includes X-ray and MRI. X-rays are useful in detecting thinning or erosions in the bony cortex produced by larger lesions. X-ray changes may be present in up to 30–60% cases. It has been documented that these changes are usually visualized when lesions are bigger than 5 mm.[7] In our series except for one (size - 4.3 mm) none of the lesions was large enough (average size was 2.7 mm) to produce X-ray changes. MRI is a useful noninvasive modality to evaluate glomus tumors and can detect lesions as small as 2 mm.[18] These lesions appear hypointense on T1W images and hyperintense on T2W images. They also show marked enhancement with gadolinium. In our study, all lesions showed contrast enhancement.[18],[19] Even though highly sensitive, there have been reports in the literature where the lesion was missed in MRI.[19]

Histologically the components of glomus tumor are glomus cells, vasculature, and smooth cells. Based on histological features they are classified into three types: solid glomus tumor (with poor vasculature and scanty smooth muscle component), glomangioma (with prominent vascular component), and glomangiomyoma (with prominent vascular and smooth muscle components).[4],[9] Solid glomus tumor contributes to 75% of cases while glomangiomas constitute 20% and the remaining 5% by glomangiomyomas. Literature also reports the histochemical staining of glomus cells are positive for vimentin and actin but are negative for desmin.[20] In our series, no immunochemistry study was done but histology showed characteristic findings of glomus tumors.

Total surgical excision is the treatment of choice for glomus tumors. Incomplete excision can lead to recurrence and persistent pain. The reported recurrence rate is 5–15%.[6],[21],[22] Most of the recurrences present with 1 year and are commonly due to the incomplete excision of the lesion.[14] Recurrence should be suspected if there is a return of pain and incomplete resolution of symptoms following surgery.[7] Delayed recurrences that occur after 1 year even though rare is usually due to the concurrent satellite lesions near the site of the original tumor.[23] Surgical approaches include transungual, lateroungual, lateral subperiosteal, and punch hole excision.[19],[24] We used transungual approach in our cases. Previous studies have reported that removal of the nail may be needed in the case of larger lesions. It is also documented in the literature that a higher rate of the nail plate deformity is associated with transungual approach compared to lateral approaches.[19] Most of the nail deformity can be prevented by meticulous repair of the nail bedpost excision of the tumor. In our study except for one case, none of the cases had nail deformity. Retaining the nail plate can act as protection of the nail bed, allowing better healing and prevent adhesions of the eponychium to the matrix. We retained nail plates in all our cases.

 Conclusion



Subungual glomus tumors need higher clinical suspicion for early diagnosis and complete surgical excision to prevent a recurrence. We noted that transungual approach with meticulous nail bed repair is met with minimum nail plate related complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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