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A GLOMUS TUMOUR WITH FOUR RECURRENCES
A GLOMUS TUMOUR WITH FOUR RECURRENCES Z. H. DAILIANA, J. L. DRAPÉ and D. LE VIET From the Institut de la Main, Clinique Jouvenet and the Service de Radiologie B, Hôpital Cochin, Paris, France
A case of a glomus tumour of the distal segment of the ring finger, with four apparent recurrences in an 8-year period, is described. The patient was treated by two different surgeons (two and three times respectively) and obtained pain free intervals of between 4 and 11 months before recurrence. Histological examination confirmed the diagnosis of a glomus tumour in all five procedures. The location of the glomus tumour was defined preoperatively by high resolution MR imaging. Journal of Hand Surgery (British and European Volume, 1999) 24B: 1: 131–132 Surgical excision of glomus tumours offers permanent relief in the majority of cases. Recurrence is usually attributed to incomplete excision (Brenner et al., 1995; Carroll and Berman, 1972; Johnson et al., 1993).
palmar aspect. On both occasions histological examination confirmed the diagnosis of a glomus tumour. High resolution MR images (Drapé et al., 1996) were obtained with a custom-built surface gradient coil and a 1.5T MR unit (Signa, General Electric). Spatial resolution reached 117 µm (three to four times higher than the resolution of the MRI obtained before the third procedure) and the location of both the glomus tumour and the postoperative scar were accurately defined (Figs 1 and 2). Although symptom-free for the last 13 months, the patient (who is now aged 45) has an inoperable orbital meningioma.
CASE REPORT A 39-year-old female patient presented to one of the authors (DLV) with a second recurrence of a subungual glomus tumour of the right ring finger. Pain and tenderness were first noted by the patient at the age of 36, with an 8-month duration before the initial diagnosis. The tumour was removed by a transungual approach and histological examination confirmed a glomus tumour. Symptoms were eliminated for a period of 4 months but their recurrence required a second procedure, 7 months after the initial one. Once more histological examination confirmed a glomus tumour. After a further symptom-free period of 4 months, a second recurrence was noted and the patient visited our centre. At that time, clinical examination revealed a hypersensitive subungual region on the ring finger and a blue spot was noted under the nail. MR images could not distinguish between recurrence and postoperative fibrosis. A lateral subperiosteal approach was used and a glomus tumour penetrating the periosteum and the nail bed was excised from the dorsal aspect of the distal phalanx. The procedure was carried out under magnification using the operating microscope, with particular attention to the surrounding periosteum and nail matrix to avoid incomplete excision. The palmar aspect of the distal phalanx was also dissected but no tumour elements were found. Histological examination confirmed that the tumour excised from the dorsal aspect of the phalanx was a glomus tumour. The symptoms disappeared for 11 months before the third recurrence and for 10 months before the fourth one. Each time symptoms included local pain and hypersensitivity. The fourth and fifth procedures were undertaken by the same lateral subperiosteal approach and at the fourth procedure a tumour from the dorsal side of the distal phalanx was excised. In the fifth procedure, with the help of a high resolution MRI, which revealed a nodule near the insertion of the flexor digitorum profundus tendon (Fig 1), a glomus tumour was excised from the
DISCUSSION Glomus tumours are usually located in the distal segments of the fingers and represent 2% of all hand tumours (Leclercq, 1989). The incidence of recurrence after surgical excision ranges from 5 to 50% (Brenner et al., 1995; Carlstedt and Lugnegard, 1983; Carroll and Berman, 1972; Van Geertruyden et al., 1996). In relation to the interval between the recurrence and the primary
Fig 1
131
Three-millimetre thick axial spin echo (TR 2000/TE 24 ms) image at the level of the base of the distal phalanx. A 2 mm tumour (arrow) is depicted on the ulnar aspect of the insertion of the FDP. The limits of the tumour are sharply defined.
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THE JOURNAL OF HAND SURGERY VOL. 24B No. 1 FEBRUARY 1999
MR images obtained before the third operation failed to distinguish between postoperative fibrosis and a new tumour, whereas high resolution MR imaging indicated a new (palmar) location of the tumour before the last operation. Although standard MR imaging can adequately detect glomus tumours (Drapé et al., 1995; 1996), only the most recent generation of MRI units provide sufficient resolution for the elucidation of complex clinical problems such as the one described. References
Fig 2
Gadolinium enhanced axial T1-weighted spin echo (TR 600/TE 24 ms) image of the distal third of the nail bed. The scar of the previous ulnar approach (arrow) has a low signal, whereas scar tissue in the thickened nail bed shows ill-defined enhancement (arrowheads).
operation, recurrences are classed as early or delayed. Early recurrences can be attributed to incomplete excision (Brenner et al., 1995; Carroll and Berman, 1972; Leclercq, 1989) or to the presence of a second tumour not diagnosed and excised in the initial operation (Ali Noor and Masbah, 1997; Gandon et al., 1992; Leclercq, 1989), whereas delayed “recurrences” are possibly due to the development of a new glomus tumour near the excision site (Carlstedt and Lugnegard, 1983; Mansat et al., 1985; Van Geertruyden et al., 1996). In the present case the hypothesis that a new tumour had developed is supported by the number of operations (five) done by two different surgeons, most with magnification and also by the presence of a glomus tumour in a different location in the distal segment at the last operation, in contrast to the location in the dorsal aspect in all four previous operations.
Ali Noor M, Masbah O (1997). Synchronous glomus tumors in a distal digit: a case report. Journal of Hand Surgery, 22A: 508–510. Brenner P, Krause-Bergmann A, Wittig K (1995). Solitäre Glomustumoren der Hand. Eine klinisch-pathologische Erfrassungsstudie. Langenbecks Archiv für Chirurgie, 380: 321–326. Carlstedt T, Lugnegard H (1983). Glomus tumor in the hand. Acta Orthopaedica Scandinavica, 54: 296–302. Carroll RE, Berman AT (1972). Glomus tumors of the hand. Review of the literature and report of 28 cases. Journal of Bone and Joint Surgery, 54A: 691–702. Drapé JL, Idy-Peretti I, Goettmann S et al. (1995). Subungual glomus tumors: Evaluation with MR imaging. Radiology, 195: 507–515. Drapé JL, Idy-Peretti I, Goettmann S, Guerin-Surville H, Bittoun J (1996). Standard and high resolution magnetic resonance imaging of glomus tumors of toes and fingertips. Journal of the American Academy of Dermatology, 35: 550–555. Gandon F, Legaillard P, Brueton R, Le Viet D, Foucher G (1992). Forty eight glomus tumors of the hand. Retrospective study and four years follow up. Annals of Hand and Upper Limb Surgery, 11: 401–405. Johnson DL, Kuschner SH, Lane CS (1993). Intraosseous glomus tumors of the phalanx: a case report. Journal of Hand Surgery, 18A: 1026–1028. Leclercq C (1989). Tumeurs des parties molles de la main. Cahiers d’Enseignement de Chirurgie de la Main, 1: 97–115. Mansat M, Bonnevialle P, Gay R, Durroux R (1985). Les tumeurs glomiques de la main. A propos de 14 cas. Annales de Chirurgie de la Main, 4: 43–50. Van Geertruyden J, Lorea P, Goldschmidt D et al. (1996). Glomus tumours of the hand. Journal of Hand Surgery, 21B: 257–260.
Received: 17 June 1998 Accepted after revision: 10 August 1998 D. Le Viet MD, Institut de la Main, Clinique Jouvenet, 6 Square Jouvenet, 75016 Paris, France. © 1999 The British Society for Surgery of the Hand Article no. jhsb.1998.0047
A case of a glomus tumour of the distal segment of the ring finger, with four apparent recurrences in an 8-year period, is described. The patient was treated by two different surgeons (two and three times respectively) and obtained pain free intervals of between 4 and 11 months before recurrence. Histological examination confirmed the diagnosis of a glomus tumour in all five procedures. The location of the glomus tumour was defined preoperatively by high resolution MR imaging. Journal of Hand Surgery (British and European Volume, 1999) 24B: 1: 131–132 Surgical excision of glomus tumours offers permanent relief in the majority of cases. Recurrence is usually attributed to incomplete excision (Brenner et al., 1995; Carroll and Berman, 1972; Johnson et al., 1993).
palmar aspect. On both occasions histological examination confirmed the diagnosis of a glomus tumour. High resolution MR images (Drapé et al., 1996) were obtained with a custom-built surface gradient coil and a 1.5T MR unit (Signa, General Electric). Spatial resolution reached 117 µm (three to four times higher than the resolution of the MRI obtained before the third procedure) and the location of both the glomus tumour and the postoperative scar were accurately defined (Figs 1 and 2). Although symptom-free for the last 13 months, the patient (who is now aged 45) has an inoperable orbital meningioma.
CASE REPORT A 39-year-old female patient presented to one of the authors (DLV) with a second recurrence of a subungual glomus tumour of the right ring finger. Pain and tenderness were first noted by the patient at the age of 36, with an 8-month duration before the initial diagnosis. The tumour was removed by a transungual approach and histological examination confirmed a glomus tumour. Symptoms were eliminated for a period of 4 months but their recurrence required a second procedure, 7 months after the initial one. Once more histological examination confirmed a glomus tumour. After a further symptom-free period of 4 months, a second recurrence was noted and the patient visited our centre. At that time, clinical examination revealed a hypersensitive subungual region on the ring finger and a blue spot was noted under the nail. MR images could not distinguish between recurrence and postoperative fibrosis. A lateral subperiosteal approach was used and a glomus tumour penetrating the periosteum and the nail bed was excised from the dorsal aspect of the distal phalanx. The procedure was carried out under magnification using the operating microscope, with particular attention to the surrounding periosteum and nail matrix to avoid incomplete excision. The palmar aspect of the distal phalanx was also dissected but no tumour elements were found. Histological examination confirmed that the tumour excised from the dorsal aspect of the phalanx was a glomus tumour. The symptoms disappeared for 11 months before the third recurrence and for 10 months before the fourth one. Each time symptoms included local pain and hypersensitivity. The fourth and fifth procedures were undertaken by the same lateral subperiosteal approach and at the fourth procedure a tumour from the dorsal side of the distal phalanx was excised. In the fifth procedure, with the help of a high resolution MRI, which revealed a nodule near the insertion of the flexor digitorum profundus tendon (Fig 1), a glomus tumour was excised from the
DISCUSSION Glomus tumours are usually located in the distal segments of the fingers and represent 2% of all hand tumours (Leclercq, 1989). The incidence of recurrence after surgical excision ranges from 5 to 50% (Brenner et al., 1995; Carlstedt and Lugnegard, 1983; Carroll and Berman, 1972; Van Geertruyden et al., 1996). In relation to the interval between the recurrence and the primary
Fig 1
131
Three-millimetre thick axial spin echo (TR 2000/TE 24 ms) image at the level of the base of the distal phalanx. A 2 mm tumour (arrow) is depicted on the ulnar aspect of the insertion of the FDP. The limits of the tumour are sharply defined.
132
THE JOURNAL OF HAND SURGERY VOL. 24B No. 1 FEBRUARY 1999
MR images obtained before the third operation failed to distinguish between postoperative fibrosis and a new tumour, whereas high resolution MR imaging indicated a new (palmar) location of the tumour before the last operation. Although standard MR imaging can adequately detect glomus tumours (Drapé et al., 1995; 1996), only the most recent generation of MRI units provide sufficient resolution for the elucidation of complex clinical problems such as the one described. References
Fig 2
Gadolinium enhanced axial T1-weighted spin echo (TR 600/TE 24 ms) image of the distal third of the nail bed. The scar of the previous ulnar approach (arrow) has a low signal, whereas scar tissue in the thickened nail bed shows ill-defined enhancement (arrowheads).
operation, recurrences are classed as early or delayed. Early recurrences can be attributed to incomplete excision (Brenner et al., 1995; Carroll and Berman, 1972; Leclercq, 1989) or to the presence of a second tumour not diagnosed and excised in the initial operation (Ali Noor and Masbah, 1997; Gandon et al., 1992; Leclercq, 1989), whereas delayed “recurrences” are possibly due to the development of a new glomus tumour near the excision site (Carlstedt and Lugnegard, 1983; Mansat et al., 1985; Van Geertruyden et al., 1996). In the present case the hypothesis that a new tumour had developed is supported by the number of operations (five) done by two different surgeons, most with magnification and also by the presence of a glomus tumour in a different location in the distal segment at the last operation, in contrast to the location in the dorsal aspect in all four previous operations.
Ali Noor M, Masbah O (1997). Synchronous glomus tumors in a distal digit: a case report. Journal of Hand Surgery, 22A: 508–510. Brenner P, Krause-Bergmann A, Wittig K (1995). Solitäre Glomustumoren der Hand. Eine klinisch-pathologische Erfrassungsstudie. Langenbecks Archiv für Chirurgie, 380: 321–326. Carlstedt T, Lugnegard H (1983). Glomus tumor in the hand. Acta Orthopaedica Scandinavica, 54: 296–302. Carroll RE, Berman AT (1972). Glomus tumors of the hand. Review of the literature and report of 28 cases. Journal of Bone and Joint Surgery, 54A: 691–702. Drapé JL, Idy-Peretti I, Goettmann S et al. (1995). Subungual glomus tumors: Evaluation with MR imaging. Radiology, 195: 507–515. Drapé JL, Idy-Peretti I, Goettmann S, Guerin-Surville H, Bittoun J (1996). Standard and high resolution magnetic resonance imaging of glomus tumors of toes and fingertips. Journal of the American Academy of Dermatology, 35: 550–555. Gandon F, Legaillard P, Brueton R, Le Viet D, Foucher G (1992). Forty eight glomus tumors of the hand. Retrospective study and four years follow up. Annals of Hand and Upper Limb Surgery, 11: 401–405. Johnson DL, Kuschner SH, Lane CS (1993). Intraosseous glomus tumors of the phalanx: a case report. Journal of Hand Surgery, 18A: 1026–1028. Leclercq C (1989). Tumeurs des parties molles de la main. Cahiers d’Enseignement de Chirurgie de la Main, 1: 97–115. Mansat M, Bonnevialle P, Gay R, Durroux R (1985). Les tumeurs glomiques de la main. A propos de 14 cas. Annales de Chirurgie de la Main, 4: 43–50. Van Geertruyden J, Lorea P, Goldschmidt D et al. (1996). Glomus tumours of the hand. Journal of Hand Surgery, 21B: 257–260.
Received: 17 June 1998 Accepted after revision: 10 August 1998 D. Le Viet MD, Institut de la Main, Clinique Jouvenet, 6 Square Jouvenet, 75016 Paris, France. © 1999 The British Society for Surgery of the Hand Article no. jhsb.1998.0047