Surgical treatment outcomes of glomus tumor of the finger

Transcription

1 Original rticle Hand Microsurg 2017;6: doi: /handmicrosurg Surgical treatment outcomes of glomus tumor of the finger Erdinc car STRCT Objectives: This study aims to evaluate the surgical treatment outcomes in patients with a glomus tumor of the finger. Patients and Methods: total of 45 patients (30 females, 15 males; mean age: 36.8 years; range, 16 to 58years) who were diagnosed with a glomus tumor of the finger and operated between January 2013 and March 2016 were included. ll patients were evaluated in terms of the main complaint on admission, duration of diagnosis, types of operation, and postoperative complications. Results: The mean follow-up was 12 (range, 8 to 26) months.the main complaint on admission was pain increased with cold application in 30 (%66.6),a swollen fingertip in nine patients (20%), and nail deformity in six patients (13.4%). 27 lesions (60%) were located in the right and 18 lesions (40%) were located in the left hand. The mean time from admission to surgery was two years (range, six months to seven years). ased on plain radiography, concave bone erosion was present in six patients. ll patients underwent preoperative magnetic resonance imaging (MRI). Subungual tumor localization was present in all patients. These patients were operated by transungual method. Postoperative recurrence was not detected in any patient. Conclusion: Glomus tumor should be considered in cases where there is severe and unexplained pain on the fingertip. Recurrence can be prevented with complete excision. Key words: Glomus tumor, magnetic resonance imaging, surgery Introduction Glomus tumors are one of the rare lesions of the hand derived from the glomus particles located in the stratum retinaculum of dermis. lthough these particles spread over the entire body, they are primarily observed in hands. They are neuromyoartherial arteriovenous anastomoses and provide thermoregulation by regulating the blood flow of the skin capillaries [1,2]. This tumor was first defined by Wood in 1812 as a painful subcutaneous nodule presenting with heat-varying hypersensitivity, intermittent severe pain, and long-lasting symptoms. In 1920, arre excised a painful subungual tumor, and the pathological definition was established by Masson in 1924 [1,3]. In 1934, Popoff defined five features of this structure: afferent arteriol, Sucquet-Hoyer canal, neuroretinacular and vascular uthor affiliations : Correspondence : Received / ccepted : Department of Orthopedics and Traumatology, Hand and Upper Extremity Surgery Division, Konya N.E University, Meram School of Medicine, Konya,Turkey Erdinc car, MD, Department of Orthopedics and Traumatology, Hand and Upper Extremity Surgery Division, Konya N.E University, Meram School of Medicine, Konya,Turkey. erdal240@gmail.com ugust 13, 2016 / October 28, Turkish Society for Surgery of the Hand and Upper Exremity

2 Treatment of glomus tumor structures, exterior collagen tissue, and primary collecting veins [4]. Glomus tumors are surrounded by capsules and numerous accompanying nerve fibers. They can be in vascular, solid, and myxoid structures depending on the dominant cell type. Most are located in the hands, accounting for 1 to 5% of all hand tumors. Occasionally, glomus tumors can be seen as atypical localizations [5]. The diameter of these tumors, which are dark redblue and often subungual, is generally between 2 and 6mm. Typical symptoms include pain, sensitivity, and cold intolerance. The pain usually expands to the proximal regions, demonstrating paroxysm and severity. Figure 2. () MRI of a glomus tumor in the distal phalanx of the fourth finger (coronal image). () MRI of a glomus tumor in the distal phalanx of the fourth finger (sagittal image). Figure 1. () Concave erosion caused by glomus tumor of the left hand, distal phalanx of the fourth finger (anteroposterior radiograph). () Concave erosion caused by glomus tumor of the left hand, distal phalanx of the fourth finger (lateral radiograph). In addition, one-third of patients have nodules or nail deformities, while another one-third have subungual lesions in the form of blue spots. Imaging studies can also show smooth concave erosions in the distal phalanx, osteoporosis, and cortex irregularities (Figure 1). In particular, magnetic resonance imaging (MRI) can aid in diagnosing lesions smaller than 5 mm (Figure 2). In the present study, we aimed to evaluate the surgical treatment outcomes in patients with a glomus tumor of the finger. Patients and Methods total of 45 patients (30 females and 15 males; mean age: 36.8 years; range: 16 to 58 years) who were diagnosed with a glomus tumor of the finger and operated on between January 2013 and March 2016 were Hand and Microsurgery 126

3 car E included. ll patients were assessed in terms of the main complaint upon admission, duration of diagnosis, types of operation, and postoperative complications. The diagnosis was made on the basis of MRI and histologically confirmed in all patients. Written informed consent was obtained from each patient. The study protocol was approved by the local Ethics Committee and the study was conducted in accordance with the principles of the Declaration of Helsinki. Surgical Technique ll patients were operated on by a single surgeon. In patients with a subungual tumor, the nail was pulled by performing two incisions in the proximal nail, and then the matrix was cut longitudinally. Following the tumor excision, the matrix was sutured with 5/0 resorbable suture material, and the nail was placed in its original location (Figure 3). fter one week, the nail, which was placed in its original location, was properly resected. Wound dressing was recommended every three days and sutures were removed three weeks later. There were no pain complaints from any of the patients, and in all that were included in this work, the pathology report was consistent with a glomus tumor. Statistical nalysis Statistical analysis was performed using Number Cruncher Statistical System (NCSS) 2007 and Performance nalysis of Systems and Software (PSS) 2008 software (NCSS LLC., Kaysville, Utah, US). Descriptive data were expressed in mean and range. The student t-test was employed to analyzed data. p value of 0.05 was considered statistically significant. Results The mean follow-up was 12 months (range: 8 to 26 months). The most frequent symptom upon admission was spontaneous increased pain or pain caused by cold application (66.6%). swollen fingertip was present in nine patients (20%), and there was a nail deformity in six patients (13.4%). The mean time from admission to surgery was two years (range: 6 months to 7 years). Figure 3. () preoperative view of a glomus tumor with subungual localization. () postoperative view of a glomus tumor. number of the patients were directly admitted to our clinic while some were referred to our clinic by a specialist of internal diseases or dermatology. Plain radiography demonstrated that concave bone erosion existed in six patients (13.4%). Postoperative recurrence was not detected in any patient (p = 0.04). Glomus tumor was most commonly seen at the age of 35 to lesions (60%) were located on the right hand while 18 lesions (40%) were featured on the left hand. There was an involvement in the first finger in 15 patients (33.3%), in the second finger in nine patients (20%), in the third finger in six patients (13.4%), and in the fourth finger in 15 patients (33.3%). Subungual tumor localization also existed in all patients. Discussion Despite careful history-taking and physical examination findings, the diagnosis of glomus tumors can be delayed in certain cases. Pain, point tenderness, and cold intolerance are pathognomonic findings [2,4]. Clinical tests, including placing hands in cold water and exerting pressure on the tumor, may aid the diagnosis procedure. In this study, the presence of tumors was mainly in 127 Hand and Microsurgery Year 2017 Volume 6 Issue

4 Treatment of glomus tumor female patients (66.6%), the mean age was 36.8 years, subungual localization was 100%, and the mean time from diagnosis to surgery was two years, all consistent with the literature [1,6]. With glomus tumors, there is a long period between the beginning of symptoms and diagnosis; therefore, patients undergo various treatments with different physicians [7]. In our study, certain patients were diagnosed seven years later and monitored by a rheumatologist or dermatologist. In addition, plain radiography and MRI were utilized as radiological diagnostic tools. In plain radiography, the majority of lesions were in the shape of a round notch on the distal phalanx. Next, all patients underwent MRI before surgery. Similarly, previous studies have suggested that preoperative MRI is an invaluable tool [8]. Further, MRI can be employed in cases that are difficult to diagnose as well as in the presence of recurrence or multilocular tumors [3,6,9,10]. dditionally, surgical excision is the treatment method for glomus tumors. lthough several surgical techniques have been described to date, we used a longitudinal excision of the bed or matrix following the resection of the nail through lifting the nail phleb in the subungual tumors. Following the repair of the bed and matrix, the nail was relocated to its original placement and the bed recovered without any deterioration. Ekin et al. [11] proposed opening a window over the nail in case of subungual tumors. Tada et al. [12] also reported that location of the resected nail piece to its original place following excision was critical for the prevention of further nail deformities with the window technique. However, it is not possible to perform this technique when the window is extended. In another study, Dailiana et al. [6] observed that lateral intervention provided a wide area for tumors of the nail bed and submatrix in subungual cases; through this approach, tumors with multiple localizations could be easily detected. lthough lateral intervention is appropriate to prevent deformities of the nail bed, the removal of the nail ensures an improved view [13]. s well, recurrence should be considered in the case of persistent pain following excision. Recurrence can be because of an inadequate excision or multiple tumor localization. In this study, recurrence was not observed in any patient. Moreover, none of the patients had multiple lesions. In conclusion, glomus tumors are rare but severe lesions that should be considered when encountering unexplained painful situations. Diagnosis is usually based on clinical findings. However, accessory methods can be used in difficult cases with multiple operations and recurrence. Ultimately, the treatment is surgical. Transungual or lateral intervention can be performed for subungual tumors, and the nail should be placed in its original position to prevent deformities [13]. Recurrence can be prevented with complete excision. Conflict of interest statement The authors have no conflicts of interest to declare. References 1. Moojen TM, Houpt P. Glomus tumors of the hand in the Netherlands: analysis of 107 patients. Eur J Plast Surg 2000;23: Carroll RE, erman T. Glomus tumors of the hand: review of the literature and report on twenty-eight cases. J one Joint Surg m 1972;54: Dalrymple NC, Hayes J, essinger VJ, Wolfe SW, Katz LD. MRI of multiple glomus tumors of the finger. Skeletal Radiol 1997;26: Newmeyer WL. Vascular disorders. In: Green DP (ed.) Operative hand surgery, Vol. 2. Churchill Livingstone, New York, 1999; Ugurlar M, Kabakas F, Ugurlar OY, Purisa H, Mersa, Ozcelik I. typically localized glomus tumors. Hand Microsurg 2016;5:doi: /handmicrosurg Dailiana Z, Pajardi G, Le Viet D, Foucher G. Les tumeurs glomiques de la main: propos d une serie de 80 patients. In: Dumontier C, (ed.) L ongle. Elsevier, Paris, 2000; Hand and Microsurgery 128

5 car E 7. Turkmen KE, Yildiz M, bdioglu, Oner K. Results of surgical treatment of glomus tumor. Hand Microsurg 2014;3: Giugale JM, Fowler JR. Glomus Tumors: Review of Preoperative Magnetic Resonance Imaging to Detect Satellite Lesions. Orthopedics 2015;38:e Theumann NH, Goettmann S, Le Viet D, Resnick D, Chung C, ittoun J, et al. Recurrent glomus tumors of fingertips: MR imaging evaluation. Radiology 2002;223: Noor M, Masbah O, Lumpur K. Synchronous glomus tumors in a distal digit: a case report. J Hand Surg m 1997;22: Ekin, Ozkan M, Kabaklıoglu T. Subungual glomus tumours: a different approach to diagnosis and treatment. J Hand Surg r 1997;22: Tada H, Hirayma T, Takemitsu Y. Prevention of postoperative nail deformity after subungual glomus resection. J Hand Surg m 1994;19: Kabakas F, Ugurlar M, Ozcelik I, Mersa, Purisa H. Surgical treatment of subungual glomus tumors: Experience with lateral subperiosteal and transungual approaches. Hand Microsurg 2016;5: Hand and Microsurgery Year 2017 Volume 6 Issue