Glomus Tumour Of The Forearm

 Aneel Bhangu*, Sanjay Joseph**, Richard Dias***

* ST1 Trauma and Orthopaedics
**Registrar Trauma and Orthopaedics
***Consultant Orthopaedic and Hand Surgeon  
Department of Trauma and Orthopaedics, Royal Wolverhampton Hospitals NHS Trust, Wednesfield

Abstract:

Glomus tumours are uncommon tumours which most commonly present in the fingers, where extra-digital tumours are reported as rare occurrences. Here we present a case of a glomus tumour of the forearm and review the presentation with the modern radiological appearances of these tumours. We present typical MRI images of the tumour and discuss that extra-digital sites may not be as rare as suspected.

J.Orthopaedics 2008;5(1)e18

 Keywords:
glomus tumour; forearm; MRI
Case Report:

We report the case of a 26 year old man who presented with a 12 month history of insidious onset, discreet lump of the forearm which became increasingly painful, especially in the cold, but did not increase in size. On examination, the lump seemed superficial and was exquisitely tender to palpation. There was no overlying erythema or any other signs of local change, inflammation or invasion.  

An MRI scan was performed to assess the swelling and to assess depth and invasion. Figures 1 and 2 show a 1cm diameter, well circumscribed oval lesion contained to the subcutaneous tissues, with no abnormality of the underlying muscle. It exhibited homogenous enhancement with contrast which is classical of a glomus tumour (figure 2).  

The patient underwent local excision of the lump where an encapsulated hemangiomatous lump was removed. Subsequent histology confirmed the diagnosis of a glomus tumour with complete margins of excision. At review appointments, the patient was completely symptom free. 

Figure 1 and 2: a well circumscribed oval lesion is found in the subcutenous lesions (marked as 9.2mm on figure 1). Upon administration of contrast, the lesion enhances (figure 2).

Discussion :

Glomus tumours are benign neoplasia arising from arteriovenous anastamoses found in the skin and subcutaneous skin of the extremities, where they account for less than 5% of all hand tumours. They are typically found subungally, that being on the finger tip pulp. Symptomatically they have been classically described as presenting with intermittent periods of pain, pain to palpation and pain in cold conditions 1-3.  

However, glomus tumours have been reported in many ‘extra-digital’ locations of the body, including most sites of the upper and lower limbs, the visceral organs, the lungs and trachea and the face and nose 1-9. Although it is recognised that they are typically associated with the fingers and hands, our patient adds to the literature of extra-digital locations.  

Whilst ultrasound examination has been described as a traditional first line investigation 10-12, more recently the advantages of MRI scanning for these extra-digital tumours have replaced it 13-16. The characteristic finding is a well-circumscribed lesion in the subcutaneous tissues, which is enhancing on administration of contrast 13-15, as in our patient’s case. MRI has the advantages of assessing local and deep soft tissues for evidence of invasion and other tumours, and so MRI scanning should be considered the modern first line investigation of suspected glomus tumours, both in the hand and extra-digitally. It can be considered to be effective in identifying glomus tumours (sensitivity) but not necessarily excluding them (specificity) 16.  

Histology of these tumours reveals an encapsulated lesion with no mitotic activity. They contain an afferent arteriole and collecting venule which are surrounded by rounded glomus cells. They may contain smooth muscle and non-myelinated nerve endings.  

In terms of forearm tumours, pain in a well-circumscribed subcutaneous lesion is the predominant feature 17-18 which should arouse suspicion and prompt MRI scanning with subsequent surgical excision. However, apt clinicians should consider the differential diagnosis in such situations, which include lipomas, neuroma, cysts and rarely soft tissue sarcomas. All doctors should be familiar with the features of lumps suspicious of malignancy: pain, deep seated lumps, size >5cm and rapid growth 19. In contrast, glomus tumours of the forearm are often <1cm in diameter, are superficial but are painful.

Conclusion:

 Glomus tumours are still predominately a tumour of the hand, although they should be considered in the differential diagnosis of arm lumps and may be more common in extra-digital locations than suspected. The clinical presentation is often with pain, lesions are typically less than 1cm in diameter and superficial, and modern first line investigation is with MRI scanning. The treatment is solely surgical excision, where the final diagnosis is confirmed on histology.

Reference :

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15. Matloub HS, Muoneke VN, Prevel CD et al. Glomus tumor imaging: use of MRI for localization of occult lesions. J Hand Surg [Am]. 1992 May;17(3):472-5.

16. Al-Qattan MM, Al-Namla A, Al-Thunayan A, et al. Magnetic resonance imaging in the diagnosis of glomus tumours of the hand. J Hand Surg [Br]. 2005 Oct;30(5):535-40.

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18. Moor EV, Goldberg I, Westreich M. Multiple glomus tumor: a case report and review of the literature. Ann Plast Surg. 1999 Oct;43(4):436-8.

19. Johnson CJ, Pynsent PB, Grimer RJ. Clinical features of soft tissue sarcomas. Ann R Coll Surg Engl. 2001 May;83(3):203-5.  

This is a peer reviewed paper 

Please cite as : Aneel Bhangu : Glomus Tumour Of The Forearm

J.Orthopaedics 2008;5(1)e18

URL: http://www.jortho.org/2008/5/1/e18

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