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Leiomyoma of the hand: a case report
Chirurgie de la main 24 (2005) 193–195 http://france.elsevier.com/direct/CHIMAI/
Cas clinique
Leiomyoma of the hand: a case report Leiomyome de la main: à propos d’un cas clinique A. Maresca a,*, C. Gagliano b, A. Marcuzzi b a
b
Orthopedics Institute Rizzoli, Via Pupilli n. 1, 40136 Bologna, Italy The Hand Surgery and Microsurgery Unit, Modena Hospital, Via del Pozzo n. 71, 41100 Modena, Italy
Abstract We report a case of leiomyoma of the finger in the right hand of a 12-year-old boy: a rare site for localization and unusual for age. This is a benign tumor originating from non-striated muscle that is very uncommon in the hand. The uterus is considered the most common location for leiomyoma and when it occurs in the extremities, it is more common in the leg, ankle and foot. It usually occurs in the third and fourth decades of life and it is rarely diagnosed before surgery as the diagnosis can only be confirmed histologically. © 2005 Elsevier SAS. All rights reserved. Résumé Nous rapportons un cas de leiomyome d’un doigt de la main droite chez un garçon de douze ans ; lésion rare tant pour la localisation que pour l’âge. Il s’agit d’une néoplasie peu agressive des muscles non striés et sa localisation au niveau de la main est très rare. L’utérus est considéré comme la localisation la plus fréquente. La localisation au niveau des extrémités est plus fréquente au membre inférieur (notamment jambe, cheville et pied). Elle est typique dans la troisième, quatrième décade de vie et rarement diagnostiquée avant l’opération. Seul l’examen histologique peut confirmer la diagnostic. © 2005 Elsevier SAS. All rights reserved. Keywords: Leiomyoma; Hand; Benign tumor Mots clés : Leiomyome ; Main ; Néoplasie bénigne
1. Introduction
2. Case report
Leiomyoma is a benign solitary tumor of smooth (nonstriated) muscle origin and is distributed wherever smooth muscle is present [2–5,8]. Leiomyomas of the hand are extremely uncommon [1,4,6,8,10]. In general the leyomioma is seen more frequently in women than men, most often in the third and fourth decades of life [7,9]. It should be included in the differential diagnosis of subcutaneous masses of the extremities [4].
A 12-year-old right hand dominant male, presented with a 1-year history of a progressively enlarging, painless mass in the volar aspect of his right little finger (Fig. 1). Physical examination revealed a painless 1 × 1 cm round, freely movable mass at the base of the little finger on the flexor surface. The tumor seemed like a solitary subcutaneous nodule, with firm consistency, without any associated sensory or motor impairment. The overlying skin was normal. There was no history of trauma and no family history. The X-ray and MRI (Fig. 2) examination of the right hand showed a soft tissue mass without bone involvement and without microcalcification. Excision of the benign tumor originating from nonstriated muscle was performed under brachial-plexus block anesthesia and tourniquet control. Macroscopic description
* Corresponding author. E-mail address: [email protected] (A. Maresca). 1297-3203/$ - see front matter © 2005 Elsevier SAS. All rights reserved. doi:10.1016/j.main.2005.04.004
194
A. Maresca et al. / Chirurgie de la main 24 (2005) 193–195
Fig. 1. Painless tumor at the base of the little finger.
underlined a round and encapsulated, grayish nodule measuring 2 × 1,5 × 1 cm, whose cut surface showed small, white dots (Fig. 3). The microscopic features demonstrated a capsulated lesion composed of elongated cell white monomorphic cigar-shaped nuclei and no atypias. The mitotic index was below 1 × 10 HPF. Diffuse microcalcifications were present (Fig. 4). The immuno histochemical phenotype was positive for smooth muscle actin but negative for S-100 protein and CD 34. In conclusion the diagnosis was: leyomioma. At 6 months follow-up the incision had healed, motor and sensory function were intact and there was full range of motion. Neither recurrence or surgical morbidity were observed. There was no evidence of other masses elsewhere in the body.
3. Discussion and conclusion Leiomyoma is a benign soft tissue tumor that originates in any location where smooth muscle is present [2–5,8]. The uterus is considered the most common location for leiomyoma [1,7,10]; when it occurs in the extremities, it is more common in the leg, ankle and foot [1,8,10] than it is in the upper extremity [1,4,8]. It is very rare in the hand, presumably because of the paucity of smooth muscle in the hand and arises from the non-striated muscles of the upper extremity (erector pili, the sweat glands, and vascular walls) and then in this location it appears to be associated with vascular structures [2,4,5,8]. Vascular leiomyoma arises from tunica media layer of veins [2,4,6]. In the digit it is located on the volar surface, most frequently at the base near the neurovascular bundle and is not seen distal to the DIP joint [9]. This is an important point in differentiating a vascular leiomyoma from a glomus tumor.
Fig. 2. A: MRI in A-P: no bone and tendons involvement at the base of the little finger; B: MRI in L-L: no bone and tendons involvement at the base of the little finger.
The tumor generally is quite small, most being less than 1 cm in greatest dimension [1–3]. Although vascular leiomyoma is known to be a painful nodule, the most characteristic subjective symptom of a leyomioma is tenderness that progresses to pain, spontaneous or paroxysmic but is exceptional in the hand. On the contrary, vascular leiomyoma in the arm or forearm seems much more likely to produce pain [4,10]. When pain is associated with these lesions, it is usually attributed to active contracture of the tumor smooth muscle elements resulting in local ischemia [4,10]. Physical examination reveals a well circumscribed and firm mass. On the cut surface it has a fasciculated or whorled, grayish-white glistening appearance [3,5,9].
A. Maresca et al. / Chirurgie de la main 24 (2005) 193–195
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Microscopic examination reveals a nodule composed of interlacing bundles of smooth non-striated muscle with large vascular spaces. Throughout the lesions are scattered thin walled vessels that are on occasion associated with small areas of calcification. Myofibrils are identified by electron microscopy [3,4]. Radiologically, the X-ray shows a soft tissue mass with microcalcifications on the finger without bone involvement [3]. Treatment of a leiomyoma of the hand is surgical. The usual treatment is simple excision of the mass and ligation of feeding vessels [1–6,8,10]. The operation is usually simple and effective, but the tumor occasionally lies in close proximity to a nerve and vessel, especially when located on the volar surface of the hand. In these cases magnifying loupes are recommended. These tumors have not been known to metastasize [3]. Complete excision rarely leads to recurrence [1–4].
Acknowledgements Fig. 3. Vessel loop is around the radial neurovascular bundle. The tumor is well encapsulated.
Sara Leoncini, Institute of General Pathology, Policlinico di Modena.
References [1]
Fig. 4. Histological examination revealed a nodule composed of interlacing bundles of mooths non-striated muscle and feature of microcalcifications.
Clinical examination may encompass an extensive differential diagnosis including fibroma, ganglion, lipoma, foreign body granuloma, giant cell tumor of the tendon sheath, glomus tumor, hemangioma, neurofibroma, neurilemmoma, spindle cell sarcoma, and nodular melanoma [1,4]. The tumor is rarely diagnosed before surgery, because only the histological examination will confirm the diagnosis [1,3].
Boyd R, Bhatt B, Mandell G, Saxe A, Detroit MI. Leiomyoma of the hand: a case report and review of the literature. J Hand Surg [Am] 1995;20A(1):24–6. [2] Callé SC, Eaton RG, Littler JW. Vascular leiomyomas in the hand. J Hand Surg 1994;19A(2):281–6 (New York). [3] Campanacci M. Bone and soft tissue tumours. 2nd Edition, Piccin Nuova Libreria, Springer-Verlag. Duhig JT, Ayer JP. Vacular leiomyoma: a study of 61 cases. Arch Pathol 1959;68:424–30. [4] Freedman AM, Meland BN. Angioleyomiomas of the extremities: report of a case and review of the Mayo Clinic experience. Plast Reconstr Surg 1989;83(2):328–31. [5] Hachisuga T, Hashimoto H, Enjoji M. Angioleiomyoma: a clinicopathologic reappraisal of 562 cases. Cancer 1984;54:126–30. [6] Magner D, Hill DP. Encapsulated angiomyoma of the skin and subcutaneous tissues. Am J Clin Pathol 1961;35:137–41. [7] Robbins SL, Cotran RS, Kumar V. In: Pathologic basis of disease, 3rd ed. Philadelphia: W.B. Saunders; 1984. p. 1136–7. [8] Robinson SC, Kalish RJ. Leiomyoma in the hand. A case report. Clin Orthop 1990;255:121–3. [9] Uchida M, Kojima T, Hirase Y, Lizuka T. Clinical characteristics of vascular leiomyoma of the upper extremitiy: report of 11 cases. Br J Plast Surg 1992;45:547–9. [10] Yang S, Williams RJ, Bear BJ, McCormack RR. New York City. Leiomyoma of the hand in a child who has the human immunodeficiency virus. J Bone Jt Surg 1996;78-A(12):1904–6.
Cas clinique
Leiomyoma of the hand: a case report Leiomyome de la main: à propos d’un cas clinique A. Maresca a,*, C. Gagliano b, A. Marcuzzi b a
b
Orthopedics Institute Rizzoli, Via Pupilli n. 1, 40136 Bologna, Italy The Hand Surgery and Microsurgery Unit, Modena Hospital, Via del Pozzo n. 71, 41100 Modena, Italy
Abstract We report a case of leiomyoma of the finger in the right hand of a 12-year-old boy: a rare site for localization and unusual for age. This is a benign tumor originating from non-striated muscle that is very uncommon in the hand. The uterus is considered the most common location for leiomyoma and when it occurs in the extremities, it is more common in the leg, ankle and foot. It usually occurs in the third and fourth decades of life and it is rarely diagnosed before surgery as the diagnosis can only be confirmed histologically. © 2005 Elsevier SAS. All rights reserved. Résumé Nous rapportons un cas de leiomyome d’un doigt de la main droite chez un garçon de douze ans ; lésion rare tant pour la localisation que pour l’âge. Il s’agit d’une néoplasie peu agressive des muscles non striés et sa localisation au niveau de la main est très rare. L’utérus est considéré comme la localisation la plus fréquente. La localisation au niveau des extrémités est plus fréquente au membre inférieur (notamment jambe, cheville et pied). Elle est typique dans la troisième, quatrième décade de vie et rarement diagnostiquée avant l’opération. Seul l’examen histologique peut confirmer la diagnostic. © 2005 Elsevier SAS. All rights reserved. Keywords: Leiomyoma; Hand; Benign tumor Mots clés : Leiomyome ; Main ; Néoplasie bénigne
1. Introduction
2. Case report
Leiomyoma is a benign solitary tumor of smooth (nonstriated) muscle origin and is distributed wherever smooth muscle is present [2–5,8]. Leiomyomas of the hand are extremely uncommon [1,4,6,8,10]. In general the leyomioma is seen more frequently in women than men, most often in the third and fourth decades of life [7,9]. It should be included in the differential diagnosis of subcutaneous masses of the extremities [4].
A 12-year-old right hand dominant male, presented with a 1-year history of a progressively enlarging, painless mass in the volar aspect of his right little finger (Fig. 1). Physical examination revealed a painless 1 × 1 cm round, freely movable mass at the base of the little finger on the flexor surface. The tumor seemed like a solitary subcutaneous nodule, with firm consistency, without any associated sensory or motor impairment. The overlying skin was normal. There was no history of trauma and no family history. The X-ray and MRI (Fig. 2) examination of the right hand showed a soft tissue mass without bone involvement and without microcalcification. Excision of the benign tumor originating from nonstriated muscle was performed under brachial-plexus block anesthesia and tourniquet control. Macroscopic description
* Corresponding author. E-mail address: [email protected] (A. Maresca). 1297-3203/$ - see front matter © 2005 Elsevier SAS. All rights reserved. doi:10.1016/j.main.2005.04.004
194
A. Maresca et al. / Chirurgie de la main 24 (2005) 193–195
Fig. 1. Painless tumor at the base of the little finger.
underlined a round and encapsulated, grayish nodule measuring 2 × 1,5 × 1 cm, whose cut surface showed small, white dots (Fig. 3). The microscopic features demonstrated a capsulated lesion composed of elongated cell white monomorphic cigar-shaped nuclei and no atypias. The mitotic index was below 1 × 10 HPF. Diffuse microcalcifications were present (Fig. 4). The immuno histochemical phenotype was positive for smooth muscle actin but negative for S-100 protein and CD 34. In conclusion the diagnosis was: leyomioma. At 6 months follow-up the incision had healed, motor and sensory function were intact and there was full range of motion. Neither recurrence or surgical morbidity were observed. There was no evidence of other masses elsewhere in the body.
3. Discussion and conclusion Leiomyoma is a benign soft tissue tumor that originates in any location where smooth muscle is present [2–5,8]. The uterus is considered the most common location for leiomyoma [1,7,10]; when it occurs in the extremities, it is more common in the leg, ankle and foot [1,8,10] than it is in the upper extremity [1,4,8]. It is very rare in the hand, presumably because of the paucity of smooth muscle in the hand and arises from the non-striated muscles of the upper extremity (erector pili, the sweat glands, and vascular walls) and then in this location it appears to be associated with vascular structures [2,4,5,8]. Vascular leiomyoma arises from tunica media layer of veins [2,4,6]. In the digit it is located on the volar surface, most frequently at the base near the neurovascular bundle and is not seen distal to the DIP joint [9]. This is an important point in differentiating a vascular leiomyoma from a glomus tumor.
Fig. 2. A: MRI in A-P: no bone and tendons involvement at the base of the little finger; B: MRI in L-L: no bone and tendons involvement at the base of the little finger.
The tumor generally is quite small, most being less than 1 cm in greatest dimension [1–3]. Although vascular leiomyoma is known to be a painful nodule, the most characteristic subjective symptom of a leyomioma is tenderness that progresses to pain, spontaneous or paroxysmic but is exceptional in the hand. On the contrary, vascular leiomyoma in the arm or forearm seems much more likely to produce pain [4,10]. When pain is associated with these lesions, it is usually attributed to active contracture of the tumor smooth muscle elements resulting in local ischemia [4,10]. Physical examination reveals a well circumscribed and firm mass. On the cut surface it has a fasciculated or whorled, grayish-white glistening appearance [3,5,9].
A. Maresca et al. / Chirurgie de la main 24 (2005) 193–195
195
Microscopic examination reveals a nodule composed of interlacing bundles of smooth non-striated muscle with large vascular spaces. Throughout the lesions are scattered thin walled vessels that are on occasion associated with small areas of calcification. Myofibrils are identified by electron microscopy [3,4]. Radiologically, the X-ray shows a soft tissue mass with microcalcifications on the finger without bone involvement [3]. Treatment of a leiomyoma of the hand is surgical. The usual treatment is simple excision of the mass and ligation of feeding vessels [1–6,8,10]. The operation is usually simple and effective, but the tumor occasionally lies in close proximity to a nerve and vessel, especially when located on the volar surface of the hand. In these cases magnifying loupes are recommended. These tumors have not been known to metastasize [3]. Complete excision rarely leads to recurrence [1–4].
Acknowledgements Fig. 3. Vessel loop is around the radial neurovascular bundle. The tumor is well encapsulated.
Sara Leoncini, Institute of General Pathology, Policlinico di Modena.
References [1]
Fig. 4. Histological examination revealed a nodule composed of interlacing bundles of mooths non-striated muscle and feature of microcalcifications.
Clinical examination may encompass an extensive differential diagnosis including fibroma, ganglion, lipoma, foreign body granuloma, giant cell tumor of the tendon sheath, glomus tumor, hemangioma, neurofibroma, neurilemmoma, spindle cell sarcoma, and nodular melanoma [1,4]. The tumor is rarely diagnosed before surgery, because only the histological examination will confirm the diagnosis [1,3].
Boyd R, Bhatt B, Mandell G, Saxe A, Detroit MI. Leiomyoma of the hand: a case report and review of the literature. J Hand Surg [Am] 1995;20A(1):24–6. [2] Callé SC, Eaton RG, Littler JW. Vascular leiomyomas in the hand. J Hand Surg 1994;19A(2):281–6 (New York). [3] Campanacci M. Bone and soft tissue tumours. 2nd Edition, Piccin Nuova Libreria, Springer-Verlag. Duhig JT, Ayer JP. Vacular leiomyoma: a study of 61 cases. Arch Pathol 1959;68:424–30. [4] Freedman AM, Meland BN. Angioleyomiomas of the extremities: report of a case and review of the Mayo Clinic experience. Plast Reconstr Surg 1989;83(2):328–31. [5] Hachisuga T, Hashimoto H, Enjoji M. Angioleiomyoma: a clinicopathologic reappraisal of 562 cases. Cancer 1984;54:126–30. [6] Magner D, Hill DP. Encapsulated angiomyoma of the skin and subcutaneous tissues. Am J Clin Pathol 1961;35:137–41. [7] Robbins SL, Cotran RS, Kumar V. In: Pathologic basis of disease, 3rd ed. Philadelphia: W.B. Saunders; 1984. p. 1136–7. [8] Robinson SC, Kalish RJ. Leiomyoma in the hand. A case report. Clin Orthop 1990;255:121–3. [9] Uchida M, Kojima T, Hirase Y, Lizuka T. Clinical characteristics of vascular leiomyoma of the upper extremitiy: report of 11 cases. Br J Plast Surg 1992;45:547–9. [10] Yang S, Williams RJ, Bear BJ, McCormack RR. New York City. Leiomyoma of the hand in a child who has the human immunodeficiency virus. J Bone Jt Surg 1996;78-A(12):1904–6.