JSTC
Journal of Surgery and Trauma Care, Vol. 1 No. 2 (2019) p. 1-3
Journal of Surgery and Trauma Care
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*Corresponding author: [email protected] 2019 FAZ Publishing. All right reserved.
Extradigital glomus tumour in the arm: A case report
Mohd Shaffid Md Shariff1,*, Razrim Rahim1, Affirul Chairil1
1Faculty of Medicine and Allied Health, Universiti Sains Islam Malaysia (USIM), MALAYSIA
Received 20 August 2019;
Accepted 30 September 2019;
Available online 30 September 2019
1. Introduction
Glomus tumors are rare vascular tumors that are found most commonly in the hand. Although the tumors are benign, they can cause intense focal pain. Patients often go undiagnosed or misdiagnosed for many years because the tumors are small, usually not palpable, and have varying presentations. A combination of magnetic resonance imaging and clinical examination is used to support the diagnosis.
Surgical excision normally provides complete pain relief. An awareness of the diagnosis is critical to preventing an unnecessary delay in treatment
2. Case report
A 64-year-old lady with a known case of hypertension, presented with a history of left arm pain for 3 years. The pain described as sharp in nature. It was localised at the middle of her left arm and non-radiating. The pain aggravated by touch and cold temperature. Even a flow of water during shower may exacerbate the pain. A bluish skin discoloration appears during severe pain. All modalities of analgesia failed to relieve it.
On physical examination, there was a subcutaneous swelling localised at the medial aspect of left arm measuring 0.5 x 0.5 mm. It was tender on palpation and very sensitive to touch and therefore difficult to delineate the border. Tinel sign was negative. Love’s test and cold sensitivity test was positive We proceeded with an excision biopsy of the swelling under local anaesthesia (Figure 1). A well subscribed encapsulated round mass measuring 0.5 x 0.5 cm was excised and sent for
histopathological examination (Figure 2). Histopathological examination results came back 2 weeks later and was reported as glomus tumour (Figure 3). She was pain free post operation.
Her pain and symptoms resolved totally post operation.
Fig 1. – Pre-operative photo of the tumour area (marked with red circle)
Abstract: We report a case of a 64-year-old lady preasented with a history of localised pain over the left arm which was aggravated by shower and cold weather. Physical examination showed bluish purplish swelling over the left arm which was tender. Diagnosis of glomus tumour was made.
Glomus tumour are rare benign vascular related tumour and most interesting tumour of the hand because of its unique clinical findings. Clinically, glomus tumour are chracterized by a triad of severe pain, localising tenderness and cold sensitivity. The lesion usually located in the hand, but it may occur elsewhere. With good and precise clinical judgement, the diagnosis of glomus tumour can be made. We report a rare case of extradigital glomus tumour that present in the arm.
Keywords: glomus, tumour, extradigital
Shariff, M. S. M. et al.,Journal of Surgery and Trauma Care, Vol. 1 No. 2 (2019) p. 1-3
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Fig 2. – Photo showing the excised tumour
Fig 3. – Histology of the tumour
3. Discussion
Glomus tumour is a benign hamartoma that account for 1% to 5% of all soft tissues tumours of the hand1. It is usually benign, slow growing and excruciatingly painful tumour. They arise from the glomus apparatus located in the subcutaneous tissue. It is neuromyoarterial in origin and function as thermal regulation of the surrounding skin area. It was first described clinically by Wood in 1812 with Masson reported its histology later in 19242. The tumour occurred at all age groups, had a female to male ratio of 13.1:13
Classically, glomus tumour present as subungal mass in the fingertip4. Atypical presentation of glomus tumour is relatively rare. However it may appear elsewhere in the body other than the fingers and described as extradigital glomus tumour. A pathological review of 52 atypical glomus tumour showed tumour locations range from the thigh (n=11), calf and ankle (n=7), foot (n=4), trunk and abdomen (n=7), arm (n=9), wrist and hand (n=7), lung (n=2), stomach (n=1) and L3 vertebra (n=1)5. There was also case reported by Sapuan J and colleagues regarding glomus tumour of the second toe6. As for the upper limb, White and Jewer reported a glomus tumour of the medial epicondyle of the right arm7
Extradigital glomus tumour may be difficult to diagnose.
Our different diagnosis includes neuroma and hemangioma.
The diagnosis of glomus tumour is done primarily by precise clinical examination. Sapuan J and colleagues6 reported that the patient sometimes presented late because of a unawarenes of the general practitioner with the clinical findings which contribute to the delay in the diagnosis. Imaging techniques such as plain radiography, ultrasonography, magnetic resonance imaging and angiography may only show the precise location and size of the tumour not the specific image of the tumour. We would suggest that good clinical judgement with positive Love’s test8 and cold sensitivity test is good enough to make a diagnosis of glomus tumour. Hildreth’s test 9 may also be done to support the diagnosis but it depends on the location of the tumour to permits the application of the torniquet.
Bhaskaranand and Navadgi in 2002 stated that cold sensitivity and Hildreth’s test have sensitivities of 100% and 77.4%
respectively and specificities of 100%. Love’s pin test had a sensitivity of 100%. Love and Hildreth’s test showed 78%
accuracy, whereas the cold sensitivity test is 100% accurate10. This is also supported by Van Geertruyden et al in 1996 conclude that the diagnosis of glomus tumour depends on clinical suspicion in 90% of the cases11. If the tumour is diagnosed early, patients will not be subjected to unnecessary treatment and referrals.
Three distinct histologic type of glomus tumour has been described. Type I is a mucoid hyaline type, Type II is a solid type (classically referred to as glomus tumour) and Type III is an angiomatous type4. Our patient having histiologic Type II glomus tumour.
The treatment of glomus tumour is primarily surgery.
Careful dissection and complete excision of the tumour almost always offer permanent relief11. The recurrence rate is 13% 3. If another tumour develops within weeks after excision, it is believed that recurrence resulted from inadequate excision.
However, if the recurrence is delayed for years it is thought to be the result of development of new glomus tumour12. In our patient the symptoms resolved totally after the excision
4. Conclusion
Extradigital glomus tumour is not uncommon and good clinical knowledge together with proper investigation may help in making early diagnosis of this illness.
References
1. Tuncali D, Yilmaz AC, Terzioglu A, et al. Multiple occurrences of different histologic types of the glomus tumor. J Hand Surg 2005;30-A(1):161-4.
2. Shugart RR, Soule EH, Johnson EW. Glomus Tumor.
Surg Gynecol Obstet 1963;117:334-40.
3. Rashdeen FM. Glomus tumour: A retrospective review of 15 years experience in a single institution.
. Malaysian Orthopaedic Journal 2011;5(3):8-12.
4. Erin M. Mcdermott A-PCW. Glomus Tumour. J Hand Surg 2006;31A:1397-400.
5. Folpe AL, Fanburg-Smith JC, Miettinen M, et al.
Atypical and malignant glomus tumors: analysis of 52 cases, with a proposal for the reclassification of glomus tumors. Am J Surg Pathol 2001;25(1):1-12.
Journal of Surgery and Trauma Care, Vol. 1 No. 2 (2019) p. 1-3
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6. Sapuan J, Paul AG, Abdullah S. Glomus tumor in the second toe: a clinical insight. J Foot Ankle Surg 2008;47(5):483-6.
7. White CP, Jewer DD. Atypical presentation of a glomus tumour: A case report. Can J Plast Surg 2006;14(4):237-8.
8. Love JG. Glomus tumors. Minn Med 1949;32(3):275-7.
9. Giele H. Hildreth's test is a reliable clinical sign for the diagnosis of glomus tumours. J Hand Surg 2002;27-B(2):157-8.
10. Bhaskaranand K, Navadgi BC. Glomus tumour of the hand. J Hand Surg 2002;27-B(3):229-31.
11. Van Geertruyden J, Lorea P, Goldschmidt D, et al.
Glomus tumours of the hand. A retrospective study of 51 cases. J Hand Surg Br 1996;21-B(2):257-60.
12. Vasisht B, Watson HK, Joseph E, et al. Digital glomus tumors: a 29-year experience with a lateral subperiosteal approach. Plast Reconstr Surg 2004;114(6):1486-9.
