Subungual Region Research Articles

From diagnosis to recovery – a detailed case report on a nail bed glomus tumor

Introduction and aim. Glomus tumors represent benign neoplastic proliferations of the glomus body, an integral thermoregulatory component within the cutaneous microvasculature. Although they can manifest at various anatomical sites, they are predominantly observed in the subungual region. The tumors present as painful, firm, purplish, solitary nodules of the extremities, especially in the nail bed. They may be solitary or multiple; solitary lesions are encapsulated and most commonly subungual, while multiple tumors are unencapsulated and rarely subungual. Description of the case. Here, we present a case of multiple glomus tumors of the right hand in an 18-year-old female who presented with complaints of painful bluish discoloration of the right little finger for six years and progressive asymptomatic nodules on the right index finger for six months. A clinical examination revealed acute tenderness in both fingers. Love’s pin test and Hildreth’s test were positive. Excision of all lesions was done and sent for histopathology, which confirmed the diagnosis. The patient was symptom-free immediately following surgery. No nail deformities were noticed, and there was no recurrence of symptoms after one year of follow-up. Conclusion. The transungual approach is a safe and effective minimally invasive surgical technique for the treatment of symptomatic nail bed glomus tumors. It offers high success rates, promising cosmetic outcomes, and minimal complications. However, careful patient selection and meticulous surgical technique are essential to avoid potential nail deformities.

Superficial Acral Fibromyxoma (SAF): A Case Report

Superficial Acral Fibromyxoma (SAFM) is a benign soft tissue tumor characterized by the presence of stellate and spindle-shaped cells arranged in a storiform and fascicular pattern. This tumor is relatively rare, benign and slow-growing. If often involves peri- and subungual regions of fingers and toes in middle-aged adults, with a male predominance. This acral fibrous tumor is poorly known and its histology may suggest myxoid dermatofibrosarcoma, which carries a completely different prognosis and treatment. Thus, immunohistochemistry is extremely important to differentiate SAFM from other acral fibrous tumors. We present a case of SAFM that involved the nail matrix with canalicular dystrophy of the nail plate. This finding has not been described in the literature as of the date of publication of this case report. Hence, we believe that it is important to note this presentation so that this disease can be considered in the differential diagnosis of diseases that produce this type of nail dystrophy.

International Experience with Glomus Tumours: An Algorithm to Improve Diagnostic Accuracy

Background Glomus tumours are benign tumours which most frequently affect the upper extremities, often the subungual regions of the digits. The classic triad of presenting symptoms include cold hypersensitivity, point tenderness and paroxysmal pain. The absence of a visible lesion or a lack of a complete triad of symptoms, renders these lesions notoriously difficult to diagnose. The aim of this study is to analyse the referral pathways and misdiagnosis rates in relation to management of upper limb glomus tumours at our institution and compare this to the international experience. Methods We conducted a retrospective review of all glomus tumours treated at our institution over a twenty year period. Medical records, radiological imaging and histopathology reports were reviewed to identify patient, disease and treatment-related factors. A literature review of published case series of upper limb glomus tumours was performed to assess referral pathways, management and misdiagnosis rates. Results Twenty three upper limb glomus tumours were treated at our institution between 2000 and 2022. The mean age of diagnosis was 52.56 years (27-63 years) with a male preponderance 17/23 (74%). The overall rate of misdiagnosis was 70% based upon histological request forms at the time of surgery. The lowest rates of misdiagnosis were associated with management by hand surgery specialists. Eight published case series were identified in the literature with misdiagnosis a common phenomenon. Referral to hand surgeons appears to improves diagnostic accuracy. We present an evidence-based algorithm to recommend optimal management which may guide clinicians and improve patient outcomes.

Gastric glomus tumor mimicking neuroendocrine tumor on fine needle aspiration: a diagnostic pitfall

Abstract Introduction/Objective Glomus tumors (GT) are mesenchymal neoplasms of modified smooth muscle that most commonly affect subungual regions of distal extremities. Although they can occur everywhere in the body, gastric involvement is rare. Gastric GT is usually benign but given the overlapping morphologic and immunohistochemical features with other gastric mesenchymal tumors, GT is commonly misdiagnosed. Methods/Case Report We present two cases of gastric GT initially diagnosed as well-differentiated neuroendocrine tumor (WDNT), G1 on fine needle aspiration (FNA). A 57-year-old female presented with an incidental 1.5 cm gastric submucosal lesion discovered on endoscopy performed for esophageal food impaction. The second case is of a 73- year-old male with a 1.7 cm submucosal lesion found on endoscopy for reflux. Both lesions were located in the gastric antrum. FNA showed clusters of relatively uniform cells with moderate cytoplasm, round nuclei, and stippled chromatin. Tumor cells were focally positive for synaptophysin, while negative for CK7, CD117, DOG-1, and chromogranin. Ki-67 proliferative index was <3%. A diagnosis of WDNT, G1 was made. Subsequent partial gastrectomy showed a submucosal epithelioid neoplasm composed of cells with eosinophilic to clear cytoplasm, and distinct cellular membranes. Focally dilated, tumor-associated thin-walled vessels were noted. Immunohistochemically, the tumor was positive for SMA, calponin, and synaptophysin, and negative for CK AE1/AE3 and chromogranin, supporting the diagnosis of gastric GT. Results (if a Case Study enter NA) N/A Conclusion The rarity of gastric GT, combined with the morphological and immunohistochemical similarity with WDNT, led to diagnostic pitfalls in these cases. With the increased detection and sampling of incidental gastric lesions, cytopathologists should be aware of this uncommon tumor and its mimics, and as such, expand their differential diagnoses.

Glomus tumour: an institutional experience of 31 cases

BackgroundGlomus tumour is an uncommon soft tissue tumour which commonly occurs in the distal extremities, particularly the subungual region of the finger. Due to its rarity, there is a paucity of literature concerning glomus tumour. Therefore, this paper aims to report a case series based on our institution’s experience.MethodsA retrospective cross sectional study was performed in a single tertiary institution in Singapore. All patients diagnosed with glomus tumour confirmed on histology from January 2019 to October 2022 were included in the study. Patient demographics and clinical information (presenting signs and symptoms, tumour parameters and presence of recurrence) were retrieved from existing medical records.ResultsA total of 31 cases of glomus tumour were diagnosed from January 2019 to October 2022, and the relevant demographics and clinical presentation were reported. Majority of glomus tumours occurred in the finger (61.3%). Pain was present in almost all the cases (96.8%), while a lump was visible in less than half (48.4%). An average of 44.0 months elapsed before patients were properly diagnosed and treated. There were no cases of recurrence despite involved margins in three cases.ConclusionGlomus tumour can be easily missed if clinicians do not have an index of suspicion for it, resulting in delayed treatment. Once diagnosed, glomus tumour can be treated with complete excision with good outcomes.

Malignant Glomus Tumor of the Ureter.

Although glomus tumour is usually seen in the subungual region of the extremities, it may rarely occur in visceral organs. Approximately 1% of all glomus tumours are malignant. Malignant glomus tumours of the urinary system are extremely rare. This paper presents a case of malignant glomus tumour of the left ureter in a 41-year male patient who had undergone a simple left nephrectomy 4 years ago and presented with recurrent macroscopic haematuria. Uretectomy and mass excision were performed. No progression was observed during the 6-month post-operative follow-up. The tumour can be differentiated from other tumours by pathological and immunohistochemical examination following surgical excision. Because there are very few cases, the treatment protocol is not entirely clear. However, complete removal of the tumour is an effective treatment and can prevent local recurrence. Key Words: Malignant glomus tumour, Ureter, Treatment, Urogenital system.

S3721 A Rare Case of Glomus Tumor of the Stomach With Metastatic Spread to the Liver and Lungs

Introduction: Glomus tumors are rare mesenchymal neoplasms arising from glomus bodies and occur mostly as benign tumors located in the subungual region of the digits. Glomus tumors of the gastrointestinal tract are rare, where there may be few or no glomus bodies, and the majority are benign, rarely demonstrating malignant behavior. We present a case of a metastatic glomus tumor of the stomach, which was initially deemed benign. Case Description/Methods: We present a 72-year-old woman who underwent excision of a gastric mass with a partial gastrectomy in 2010, suspecting a Gastrointestinal stromal tumor (GIST). However, pathology findings were consistent with glomus tumor of uncertain malignant potential given borderline tumor size (2 cm) and increased mitotic activity ( >=5/50 HPF). She was not started on chemotherapy and was on surveillance. She was asymptomatic until 2016, when she presented with acute abdominal pain. Imaging showed multiple new necrotic metastases throughout the liver with pathology consistent with metastatic glomus tumor. She underwent radioembolization of the right hepatic and left hepatic artery in 2017 and continued to be symptom-free until 2019 when she presented with another episode of abdominal pain; imaging showed an increase in the number of liver lesions and underwent radioembolization with a good response. Repeat surveillance imaging in early 2020 showed a nodule in the lingula (shown in figure 1a). A CT-guided lung biopsy confirmed the diagnosis of an epithelioid neoplasm, consistent with a metastatic glomus tumor. Caris genomic testing did not show any apparent mutations, and no clear molecular targets for treatments were present. She had low ERCC1 and TOPO1, suggesting that oxaliplatin and irinotecan may be considered for treatment in case of disease progression. Discussion: Our case highlights the importance of considering glomus tumors as part of the differentials in GI mesenchymal tumors despite GIST having the highest incidence. It is known that many GI mesenchymal tumors have visual and radiological similarities, and hence a biopsy is required. Although a majority of glomus tumors are benign, obtaining histological and immunohistochemical features is still imperative to make a definitive diagnosis to detect malignant glomus tumors with metastatic potential to visceral organs as they have a poor prognosis.Figure 1.: CT Thorax (1a) and abdomen (1b) w/contrast showing epithelioid neoplasm of the lingula and hypo-dense liver mass respectively.

A digital fibromyxoid tumor: a case report

A digital fibromyxoma is a rare soft tissue tumor, which occurs in the finger and toes around the subungual and periungual region. Histopathologically, it consists of a well-circumscribed unencapsulated dermal tumor composed of spindle and stellate cells in a loose fascicular pattern embedded in a myxocollagenous stroma. We report this rare case of superficial acral fibromyxoma presenting as an asymptomatic subungual mass in the greater toe in a middle age female.

Nail as a carrier in patients with extensive tinea corporis – An observational analytical study

Dermatophytosis is a common infection which until recently used to respond satisfactorily to treatment, however clinical resistance is frequently encountered. The exact cause of treatment failure is not known. Neglecting the management of subclinical onychomycosis might be a possible cause for recurrence. This study was undertaken to detect the fungi in the nail plate and under the nail fold in patients without clinical evidence of onychomycosis. To detect the carrier state of nail plate and subungual region in patients with extensive dermatophytoses. Observational analytical study. Patients with dermatophytoses of skin without clinical involvement of nail, attending the tertiary care centre in South India were studied. Scrapings from skin lesions and under-surface of the clinically uninvolved nails, nail clipping of clinically uninvolved nail were examined by potassium hydroxide (KOH) preparation for fungus using standard methods. Of the 150 patients recruited, 147 patients (98%) revealed fungal elements on KOH mount done on skin scrapings, while 90 patients (60%) and 99 patients (66%) had positive KOH findings from nail and subungual samples respectively.We postulate that the subclinical nail involvement, without clinical evidence of fungal invasion of nail could be one of the reasons for treatment failure. It is recommended when the nail is clinically involved, more prolonged treatment is required to prevent relapse. Thus, subclinical nail involvement should also be treated as onychomycosis. We recommend that KOH mount of the nail and subungual region should be carried out in all patients with recurrent fungal infections. Tinea corporis is a recalcitrant problem with increased resistance to the treatment. Detecting the carrier state of nail and subungual region carries a significant role, and treating the same may lead to better therapeutic levels.

Epidemiological Analysis of Glomus Tumors of the Hand and Association with Recurrence Rate

Abstract Introduction Glomus tumors are benign, characterized by microvascular alteration, and mostly found in the subungual region of the hand. They are rare and associated with paroxysmal pain, tenderness on palpation, and thermal sensitivity. The aim of the present research was to analyze the epidemiology of glomus tumors and relate each of the variables with cases of recurrence. Materials and Methods A retrospective review of medical records was undertaken in our hospital to collect epidemiological numerical variables (time between the onset of symptoms and diagnosis and surgery, age, size of the tumor on magnetic resonance imaging and the histopathological examination, time until recurrence and reoperation after surgery, duration of the follow-up) and categorical variables (gender, ethnicity, laterality, affected finger, location in the hand, surgical technique, smoking, preoperative symptoms, recurrence, and comorbidities). Then, we performed a statistical analysis to identify possible associations of the hand tumors with recurrences. Results The review identified 66 patients with glomus tumors 52 of which were located in the hand. The mean age of the sample was 49 years, and it was mostly composed of white female patients. Pain was the main related symptom, and most tumors presented sizes between 5 mm and 1 cm. Among the 52 patients, 11 cases presented recurrences, with a mean time until onset of 39.4 months, but 3 of them were initially operated on at other hospitals. None of the variables was shown to be a predictor of recurrence, although we saw that bone involvement on radiographs was only present in certain cases of recurrence. Conclusion The sample studied was large for this rare disease, and reinforced previous results regarding its epidemiology. As 54% of the cases of recurrence occurred at least twice, we think that genetic, histological and immunohistochemical analyses should be the focus of futures studies, as well as a search for bone and tendon involvement.

Intraneural glomus tumor within the digital nerve: a case report

A glomus tumor is a soft tissue tumor that arises from the glomus body, a peripheral organ responsible for regulating skin temperature. It accounts for about 1% to 5% of tumors occurring in the hand, is mainly located in the subungual region, and is less than 1 cm in size. The diagnosis is mainly based on clinical symptoms, and the main symptoms are pain at the site of the glomus tumor, pinpoint tenderness, and cold intolerance. The pain is severe and usually requires surgical resection, and the results of complete resection of the tumor are good. This case report presents a 37-year-old female patient who developed pain in the radial side around the proximal interphalangeal joint of the right second finger without any traumatic history. On physical examination and imaging, a glomus tumor of the digital nerve was diagnosed and resected. After surgery, the symptoms improved and there was no recurrence. A careful examination and accurate diagnosis and treatment are necessary for symptomatic masses.

Diagnosis of glomus tumor of the elbow: A case report

IntroductionGlomus tumors are rare and often benign vascular lesions that present classically in the subungual region of the hand. Nonetheless, presentations in atypical sites have been reported over the years. However, the classic symptoms of typical glomus tumors are often absent in tumors of atypical sites.Case presentationWe present a case of an extradigital glomus tumor with a 3-year history of pain in the lateral aspect of the elbow.DiscussionThe case we present took three years and multiple visits to different clinics and specialties to reach the final diagnosis and management. It often takes longer to diagnose Glomus tumors of atypical sites and presentations. The causes could be related to the rare incidence, the atypical presentation in site and symptoms, or the diagnostic methods.ConclusionThis case report discusses the possible causes behind the diagnostic delay in extradigital glomus tumors, aiming to raise clinical awareness among primary health care physicians.

Malignant Glomus Tumor of the Kidney: A Case Report and Review of the Literature

Abstract Introduction/Objective Glomus tumors are rare neoplasms arising from the glomus body which is a specialized arteriovenous anastomosis that has a role in temperature regulation of the skin. They account for less than 2% of soft tissue tumors and typically manifest as painful nodules in the extremities, most commonly in the subungual region of the fingers and dermis of the wrist, forearm, and foot. They rarely arise in visceral organs as they lack glomus bodies. There are rare case reports of benign glomus tumors arising in the kidney, and malignant renal glomus tumors are exceedingly rare. Methods/Case Report We present a case of a 32-year-old man who was found to have a right renal mass incidentally after being involved in a motor vehicle accident. Computed tomography of the abdomen revealed a 5.3 cm enhancing mass in the posterior aspect of the inferior pole of the right kidney. Histological examination revealed a solid neoplasm composed of a pleomorphic population of cells with densely eosinophilic to pale cytoplasm, centrally located round to oval nuclei with fine nuclear chromatin and relatively inconspicuous nucleoli. Prominent lymphovascular invasion and 1 mitotic figure per 10 high power fields were also present. Areas composed of necrosis, sclerosis, hemosiderin deposition and calcification were identified. Immunohistochemical stains revealed the neoplastic cells to be positive for CD34, vimentin, smooth muscle actin, caldesmon, with focal reticulin staining around the tumor cells. Cells were negative for desmin, high and low molecular weight cytokeratins, synaptophysin, chromogranin, PAX8, and GATA3. The morphology and immunoprofile of the mass are consistent with the diagnosis of glomus tumor. Results (if a Case Study enter NA) NA Conclusion Although very rare, the presence of prominent vascular invasion, increased mitotic activity as well as necrosis are consistent with malignant behavior and support the classification as a malignant glomus tumor.

Glomus tumour of the hand: a case report and review of the literature

Glomus tumours are uncommon benign lesions, constituting 1-5% of all soft tissue neoplasia of the hands. It was first described in 1812 by Wood as painful subcutaneous nodules. The most common site for this tumour is subungual region and affects females more frequently than males. It commonly presents as pain and pinpoint tenderness and cold sensitivity.
 Being a rare tumour, its diagnosis is often delayed and cause undue anxiety to the patients. We present a case a of left index finger glomus tumour, which remained undiagnosed for many years, after being seen by multiple clinicians.

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.

Management and outcome of subungual glomus tumours: A series of 21 cases

Introduction: Glomus Tumour are vascular neoplasm that arise from glomus body. They are benign hamartomas most commonly occurring at subungual region of digits. They can cause recurrent episodes of intense lancinating pain and disability. Patients often undergo undiagnosed or misdiagnosed for many years because the tumours are small. The purpose of our study was to assess pain relief and recurrence rate after complete excision of tumour. Material and Methods: Twenty one patients were included in the study. All cases were assessed clinically and on MRI. Glomus tumour excision was done under microscope and the diagnosis was confirmed post-operatively by HPE. Pre- and Post-operative VAS scores were compared to evaluate the symptomatic outcome. Recurrence was assessed by recurrence of pain and MRI changes. Results: Out of 21 patients 18 were females and 3 were males. The mean age was 35 years. All patients showed dramatic relief of pain after surgical excision. Early diagnosis and surgical excision decreases patient's sufferings from severe pain and disability. The average improvement in VAS score was from 7.952 (pre-op) to 1.048 (post-op). No recurrence observed at 24 months follow-up. Conclusion: Glomus tumour is a rare disease, one should have a high index of suspicion for Glomus tumour in intractable chronic fingertip pain. Excision of Glomus tumour under microscope allows better tissue clearance and hence low recurrence rate.

Glomus Tumor of the Thigh

Glomus tumors are small, painful benign tumors that occur primarily in the subungual region of the hand. The presentation of glomus tumors in areas other than the hand is rare, but have been reported. Patients with glomus tumors have a prolonged history of focal pain, tenderness, and cold hypersensitivity. However, as all 3 symptoms may not present simultaneously, it can present a diagnostic challenge to clinicians and imagers, often remaining undiagnosed or misdiagnosed for many years. We report a case of an extradigital glomus tumor of the right thigh that was initially diagnosed as focal superficial thrombophlebitis. The diagnosis of glomus tumor was pathologically proven.

Minimally Invasive Transungual Tumors Enucleation With Nail Preservation for Subungual Glomus Tumors

Glomus tumors are benign neurovascular neoplasms, most commonly located in the subungual region. These subcutaneous nodules are characterized by intense pain and temperature sensitivity. Although surgical excision is the curative treatment, permanent nail deformity and recurrence are not uncommon after conventional surgery. This study evaluated the long-term efficacy of a modified transungual approach with nail preservation for removing subungual glomus tumors. Thirty-nine patients with clinically diagnosed and histopathologically proven glomus tumors treated at a medical center over a 13-year period (2007-2019) were retrospectively evaluated. The 39 patients included 28 women and 11 men (ratio, 2.5:1), with a mean age of 48.9 years. Thirty-four tumors were located in the fingers and 5 in the toes. All patients returned to normal activity soon after the surgery. At a mean follow-up of 28.8 months, all were pain free or experienced minimal pain and were satisfied with treatment outcomes. One patient (2.6%) experienced recurrence. No nail deformity was observed. The transungual approach with nail plate preservation is a novel and effective method for removing subungual glomus tumors with reduced postoperative pain and rapid healing, while preserving or improving the configuration of the nail.

Glomus tumors of the upper extremity.

Glomus tumors are uncommon and painful benign perivascular neoplasms. They usually occur in the subungual region of phalanx, and present with a classic clinical triad of localized tenderness, cold hypersensitivity, and excruciating paroxysmal pain. The aim of this study was to review 45 cases of glomus tumor according to the clinical, radiological and therapeutic characteristics, and the clinical and functional outcomes of surgical treatment. A retrospective review was made of 45 glomus tumors of the upper extremity operated on between June 2005 and January 2019. Data were collected of demographic characteristics and the diagnostic, immunohistochemical, therapeutic and postoperative clinical findings. The patients comprised 69 % females and 31 % males with a median age of 41 years at the time of surgery. The most commonly affected anatomic location was the digits (87 %). Of the 39 cases with an affected digit, there was a predominance of the middle finger in 28 % and the peri-subungual area in 51 %. There was no recurrence or need for secondary surgical intervention in any patient in this study. The mean QuickDASH score was 1.47 at mean 66 months follow-up. Glomus tumor, which is usually seen in the middle finger of middle-aged women, presents with excruciating paroxysmal pain out of proportion to the tumor size. The long-term outcomes after surgical loupe-assisted surgery with a transungual approach were seen to be good, without local recurrence and an acceptable rate of postoperative nail dystrophy.

15240 Modified transungual approach with nail preservation for subungual glomus tumor: A 13-year evaluation and experience in a medical center in Taiwan

Background: Glomus tumors are benign neurovascular neoplasms, commonly in subungual region. The clinical presentation appears as intense pain, cold sensitivity, and severe tenderness of the involved digits or toes. The permanent nail deformity and recurrence is not uncommon after conventional surgery Objective: This study was designed to evaluate the long-term efficacy of the modified transungual approach with nail-preservation for removing subungual glomus tumors.