Granular cell tumor in the hand

The Journal of HAND SURGERY

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G, Hartofilakidis-Garofalidis G. Osteoid osteoma of the terminal phalanges. Hand 1977;9:295-300. Ghiam GF, Bora FW Jr. Osteoid osteoma of the carpal bones . J HAND SURG 1978;3A:280-3. Lamb OW, Del Castillo F. Phalangeal osteoid osteoma in the hand . Hand 1981;13:291-5. Wiss DA, Reid BS. Painless osteoid osteoma of the fingers: Report of three cases. J HAND SURG 1983;8: 914-17. Alcalay M , Clarac J-P, Bontoux D. Double osteoidosteoma in adjacent carpal bones: A case report . J Bone Joint Surg [Am] 1982;64:779-80. Blair WF, Kube WJ . Osteoid osteoma in a distal radial epiphysis: case report. Clin Orthop 1977; 126: 160-1. Dahlin De. Bone tumors : General aspects and data on 6,221 cases. 3rd ed . Springfield, Illinois: Charles C Thomas, 1978;76. Lawrie TR, Aterman K. Sinclair AM. Painless osteoid osteoma: A report of two cases. J Bone Joint Surg [Am] 1970;52: 1357 -63. Azar CA . Painless osteoid-osteoma in phalanx of finger: A case of unusual presentation and symptomatology. Bull Hosp J Dis Orthop lnst 1978;39:86-91 . Esquerdo J, Fernandez CF, Gomar F. Pain in osteoid osteoma: histological facts. Acta Orthop Scand 1976; 47 :520-4. Markley JT, Dunn MJ . Prostaglandin synthesis by osteoid osteoma (Letter to the editor). Lancet 1982;2:42.

25. Huvos AG. Bone tumors: Diagnosis, treatment and prognosis . Philadelphia: WB Saunders Co 1979;26. 26. Omojola MF, Cockshott WP, Beatty EG. Osteoid osteoma: An evaluation of diagnostic modalities. Clin Radiol 1981;32:199-204. 27. Bohne WH, Levine DB, Lyden JP. 18-F scintimetric diagnosis of osteoid osteoma of the carpal scaphoid bone . Clin Orthop 1975; 107: 156-8. 28. O'Hara JP, Tegtmeyer C , Sweet DE, McCue Fe. Angiography in the diagnosis of osteoid-osteoma of the hand . J Bone Joint Surg lAm] 1975;57:163-6. 29. Fehring TK, Green NE. Negative radionuclide scan in osteoid osteoma: A case report. Clin Orthop 1984; 185:245-9. 30. Gartsman GM, Ranawat CS. Treatment of osteoid osteoma of the proximal phalanx by the use of cryosurgery. J HAND SURG 1984;9A :275-7. 31. Harcke HT. Conway JJ, Tachdjian MO, et al. Scintigraphic localization of bone lesions during surgery. Skeletal Radiol 1985;13:211-16. 32. Ayala AG, Murray JA, Erling MA, Raymond AK . Osteoid osteoma: Intraoperative tetracycline-fluorescence demonstration of the nidus. J Bone Joint Surg [Am] 1986;68:747-51. 33. Rosenfeld K, Bora FW Jr, Lane JM. Osteoid osteoma of the hamate: A case report and review of the literature . J Bone Joint Surg [Am] 1973;55: 1085-7 .

Granular cell tumor in the hand A case of multifocaI granular cell myoblastoma involving the hand is reported. Granular cell tumors are uncommon benign neoplasms infrequently seen in the hand. MultifocaI occurrence is even more unusual. Clinical and pathologic diagnosis may be difficult. (J HAND SURG 12A [2 Pt 1]:800-3.)

Dennis P. Maher, M.D., Houston, Texas

From the Division of Plastic and Reconstructive Surgery, The University of Texas Medical School at Houston , Houston. Texas. Received for publication Dec. 29. 1986; accepted in revised form Feb. 27, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article . Reprint requests: Dennis P. Maher, M.D., Division of Plastic and Reconstructive Surgery, The University of Texas Medical School at Houston, 6431 Fannin, MSB 4152, Houston, TX 77030.

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ranular cell tumors are uncommon benign neoplasms that were originally described by Abrikossoff' in 1926 as granular cell myoblastomas. These lesions generally occur as isolated masses, but are multi focal in 10% to 25% of cases . 2-5 The most common site of involvement is the tongue; involving 40% of the total cases. 4-6 Sites less frequently observed include the subcutaneous tissues, the gastrointestinal

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Fig. 1. Granular cell tumor. (Hematoxylin and eosin stain. Original magnification x 100.)

tract (esophagus, stomach, appendix), respiratory tract, genitourinary tract, brain, and skeletal muscle. 2. 4-7 A patient with a granular cell tumor of the dominant index finger is reported. Salient points of the diagnosis and management of these neoplasms are reviewed. Case report J. C., a 30-year-old right-handed white female laboratory technician, was seen because of a painful mass on the dorsoradial aspect of the proximal phalanx of her dominant index finger that had been present for 1 year. She was almost unable to place her hand in her pocket because of the discomfort. The mass had been asymptomatic until 1 month before the initial examination when she bumped the finger and severe burning and paresthesias with proximal radiation developed. The area became progressively more tender and bothersome. She denied any history of antecedent trauma or similar problems in the hands. The skin of the involved finger was unremarkable. Digital range of motion was normal. There was no evidence of previous injury. Sensibility on the dorsal and palmar aspects of the finger was normal. Palpation of the dorsoradial aspect of the finger demonstrated a very firm, tender 4 x 5 mm mass surrounded by an area of thickened subcutaneous tissue that measured approximately 8 x 12 mm. Percussion of the lesion produced a lancinating pain radiating from the index finger to the forearm. The area was not inflamed. There was no epitrochlear or axillary lymphadenopathy. Radiographs of the finger were normal. Surgical exploration revealed the mass located just beneath the dermis. The lesion was tan, with ill-defined margins, and measured 4 x 5 mm. The mass was very firm, almost hard. It was not encapsulated. Fibrous septa appeared to radiate from the center into the surrounding fat. The lesion was closely associated with a dorsal sensory branch of the radial nerve. There was no attachment to deep structures.

Frozen and permanent sections showed the mass to be a granular cell tumor (Figs. 1 and 2). The wound healed well postoperatively. The patient is now asymptomatic, is back at work, and new lesions have not developed. Subsequently it was learned that the patient had other subcutaneous masses on the anterior chest and back excised over the previous 15 years. These masses have been asymptomatic. Pathologic examination of the only available specimen demonstrated it to have been a granular cell tumor.

Discussion

Granular cell tumors, most commonly seen in the tongue, have been reported in most areas of the body.2.4-7 Ten percent to 20% are found in the upper extremity, predominantly in the hand and wrist. 2-5. 8 Females are affected more than males. 2-5 An increased incidence of granular cell tumors in blacks has been reported. 2. 5 The lesions are typically asymptomatic and may be present for months or years before diagnosis. 2-5 Pain and/or pruritus are presenting symptoms in only about 10% of the cases. 2-5. 7, 9-11 Histologically, granular cell tumors are composed of sheets of large, elongated cells, with abundant pale cytoplasm containing coarse, eosinophilic granules that are periodic acid-Schiff (PAS)-positive. 2. 6 When subdennal, tumor cells are arranged in groups and strands surrounded by distinctly staining bands of collagen fibers and fibroblasts. The skin overlying the mass may demonstrate pseudoepitheliomatous hyperplasia. 2 • 4, 6 This may result in mistaken clinical and/or pathological diagnoses, ranging from verrucae to squamous cell carcinoma. Granular cell tumors may appear mobile when they

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Fig. 2. Higher magnification demonstrating large polyhedral cells with pale cytoplasm. (Hematoxylin and eosin stain. Original magnification x 400.)

are located in the subcutaneous tissue or as a fixed mass when they are attached to the deep dermis. Their firm consistency raises preoperative concern about a malignant tumor. The diagnosis is confirmed after surgical removal. 2-4 Complete excision of the mass is generally curative. 2 -5 Recurrence is unusual. Multifocal granular cell tumors are seen in between 4% to 25% of cases, more often in females and blacks. 2-5 . 7. 9-12 The lesions may present synchronously, but typically develop over the course of many years. As many as 64 granular cell tumors have been removed from a single patient. 2 The histogenesis of these lesions is controversial. Abrikossoff l believed that they arose from immature striated muscle cells or myoblasts. However, in 1968, Alkek and associates 13 differentiated granular cells from striated muscle by histologic and enzymatic analysis. 13 Many authors believe that the tumor originates from Schwann cells because of the cellular characteristics and the frequent relationship of these lesions to nerve fi bers. 11. 15-17 Some maintain that they arise from smooth muscle or histiocytes. 5. 14 Yet other investigators believe that granular cells arise from multipotential precursor cells, explaining the ubiquitous nature of the tumors.2. 14 The true origin of the granular cell tumor has yet to be determined. Malignant granular cell tumors involve less than 3% of reported cases, most of these arising in the skin or subcutaneous tissue.4.5· 17 They grow more rapidly than their benign counterpart. A propensity for regional and distant metastasis is recognized. 6 . 17

Patients with granular cell tumors are seen infrequently by the hand surgeon, due in part, to the small proportion of these lesions that occur in the upper extremity. In addition, many patients are seen by dermatologists because of their concern about the changes in the overlying skin. Finally, since 10% to 15% of granular cell tumors are multifocal, the original treating physician may elect to excise similar lesions that occur in the hand and upper extremity. Our patient's case emphasizes many of the important features of granular cell tumors. She had a very firm, slowly growing mass that was asymptomatic for almost I year. The association of this mass with pain suggestive of a neuroma was somewhat misleading. She had previously been treated by several different surgeons for excisions of subcutaneous tumors, the pathologic nature of which was only revealed after retrospective analysis. REFERENCES I. Abrikossoff A. Uber myome ausgehend von der quergestreiter willkurlichen muskulatur. Virchows Arch Path Anat 1926;260:215-33. 2. Apisarnthanarax P. Granular cell tumor. J Am Acad DermatoI1981;5:171-82. 3. Silva-Lopez E, Wood OK. Granular cell myoblastoma. Curr Surg 1983;40:202-6. 4. Strong EW, McDivitt RW. Brasfield RW. Granular cell myoblastoma. Cancer 1970;25:415-22. 5. Vance SF, Hudson RP. Granular cell myoblastoma. Am J Clin Pathol 1969;52:208-1 I. 6. Lever WF, Schaumburg-Lever G. Histopathology of the skin. Philadelphia: 18 Lippincott. 1983:

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7. Price ML, MacDonald DM. Multiple granular cell tumor. Clin Exp Dermatol 1984;9:375-8. 8. Berkowitz SF, Hirsh BC, Vonderheid E. Granular cell tumor: A great masquerader. Cutis 1985;35:355-6. 9. Beeaff D. Granular cell myoblastoma. Ariz Med 1984; 41:90-1. 10. Goette DK, Olson EG. Multiple cutaneous granular cell tumors. Int J Dermatol 1982;21:271-2. 11. White SW, Gallager RL, Rodman OG. Multiple granular cell tumors. J Dermatol Surg Oncol 1980;6:57-61. 12. Kucan 10, Hagstrom WJ, Soltani K, Parsons RW. Granular cell tumor. Ann Plast Surg 1982;9:409-12.

Granular cell tumor in hand

13. Alkek DS, Johnson WC, Graham JH. Granular cell myoblastoma. Arch Derm 1968;98:543-7. 14. Christ ML, Ozzello L. Myogenous origin of a granular cell tumor of the urinary bladder. Am J Clin Pathol 1971;56:736-49. 15. Fischer ER, Wechsler H. Granular cell myoblastoma-A misnomer. Cancer 1962;15:936-54. 16. Garancis JC, Komorowski RA, Kuzma JF. Granular cell myoblastoma. Cancer 1970;25:542-50. 17. Usui M, Ishii S, Yamawaki S, Sasaki T, Minami A, Hizawa K. Malignant granular cell tumor of the radial nerve. Cancer 1977;39:1547-55.

A colonic metastatic tumor in the hand Secondary tumors in the hand are very uncommon. Of the reported cases the majority arise from primary bronchial carcinoma, with multiple secondary deposits into bone. A case is reported of bony metastasis to the middle phalanx of the small finger in a patient who had a resection of a colonic adenocarcinoma 2 years previously. (J HAND SURG 1987;12A[2 Pt 1]:803-5.)

Christopher J. Hindley, M.Ch. Orth., F.R.C.S.E., and John W. Metcalfe, M.Ch. Orth., F.R.C.S., F.R.C.S.E., Liverpool, England

We report an unusual case of an apparently isolated metastasis from a colonic carcinoma to the small finger. The literature has been reviewed to ascertain the incidence of such lesions and the differential diagnosis is discussed. Case report A 44-year-old man was referred by his family practitioner because of a 7-week history of a painful swelling of the right small finger. The radiograph was reported as showing osteo-

From the Department of Orthopaedic Surgery, Walton Hospital, Liverpool, England. Received for publication Oct. 16, 1986; accepted in revised form Jan. 16, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Mr. C. J. Hindley, M.Ch. Orth., F.R.C.S.E., 30, Highfield Rd., Ormskirk, Lancashire, L39 1NR, England.

myelitis (Fig. I). Treatment with oral fusidic acid (Fucidin) was started, and he was referred for an orthopedic opinion. A provisional diagnosis of osteomyelitis was made, and the patient was admitted for exploration of the small finger. At operation through a dorsal incision a tumor-like mass encircling and partly replacing the middle phalanx was found. An incisional biopsy showed necrotic secondary carcinoma, with a poorly differentiated adenocarcinomatous structure, consistent with a colonic primary site (Fig. 2). Clinical details concerning the previous bowel resection were then obtained, and these showed that a Dukes' Stage C colonic carcinoma had been resected from the splenic flexure 2 years previously. Subsequently, an incisional hernia had been repaired, but no intra-abdominal recurrence was noted. Routine follow-up showed no suggestion of metastatic disease. A technetium bone scan showed, in addition to the "hot spot" in the small finger, an area of increased uptake in the right elbow although this area was radiographically normal. The patient was readmitted and a ray amputation of the small finger was done. Histologic examination of the specimen showed that the previous report was confirmed, and the proximal resection line was found to be free of tumor.

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