Figure 1
T1WI, coronal plan
On T1 weighted image the mass is hypointense to the muscular tissues
Glomus tumor of the subungual region – MR and histological findings
SectionMusculoskeletal system
Case TypeClinical Cases
AuthorsPilavaki M, Papachristodoulou A, Geroukis T, Sakkas L, Petridis A, Palladas P
Connected authors
41 years, female
Clinical History
A 41 year old patient presented with an enlarging painful mass at the subungual region of the right hallux. MRI exam was performed and the findings are presented.
Imaging Findings
A 41 year old female patient with a recent history of enlarging painful mass at the subungual region of the right hallux was referred to the radiology department by his GP. She was afebrile and no history of trauma in the region was referred. There was no history of diabetes. MRI exam was performed and demonstrated a mass located in the subungual region of the right hallux. On T1 weighted images (Fig. 1) the mass was hipointense to the muscular tissues. After admission of contrast medium the tumor was strongly enhancing (Fig. 2). On T2 fat-suppressed – weighted images (Fig ures 3, 4) the mass revealed an intense high MR signal. The patient underwent surgical excision of the tumor and the cytological examination (Fig. 5) revealed glomus tumor.
Discussion
Glomus tumors represent 1-5% of soft-tissue tumors in the extremities. In pathologic examination, glomus tumors are hamartomas developed from the neuromyoarterial glomus bodies that regulate blood flow in the skin.
The normal glomus body is an arteriovenous shunt that has an important role in thermoregulation and is present throughout the body in the deepest layer of the dermis, the reticular dermis. Each glomus body is an encapsulated oval organ of 300μm in length. It is located in the subungual region, digits and palms. Glomus bodies are highly concentrated in tips of the digits, particulary beneath the nails. The nail beds of fingers and toes contain 93–501 glomus bodies per square centimeter.
At clinical examination, glomus tumors are in majority non palpable lesions, frequently found in women. They usually provoke a compression to the nail matrix and thus, the principal symptom is pain at the region. A “classic triad” of clinical findings was described which include pain, point tenderness and cold sensitivity. The disappearance of the pain after application of a tourniquet proximally on the arm (Hildreth sign) is pathognominic of a glomus tumor. Eliciting pain by applying precise pressure with the tip of a pencil (Love test) helps locate the lesion.
Most glomus tumors are iso- or slightly hyperintense to the dermal layers of the nail bed on T1-weighted MR images and strongly hyperintense on T2-weighted images. The majority of them are surrounded by a capsule which has the appearance of a dark rim on T2-weighted and contrast material-enhanced imaging. The capsule is the result of a secondary reaction of the surrounding tissue and may be incomplete.
In some cases the signal intensity on T1WI and T2WI varies. It can be low or intermediate intense reflecting the variety of its histological components. The predominant cellular pattern of glomus tumors can be divided into 3 main forms: vascular , myxoid and solid. The solid or cellular type has a slightly high signal intensity on T2WI and injection of contrast medium helps its detection. The vascular type has a very strong enhancement. When the form of the tumor is myxoid the T2 times are very long. This scheme is theoretical because most tumors are composed of a mixture of the various types.
The differential diagnosis of glomus tumor includes mucoid cysts and angioma. Mucoid cysts are painless and at MRI imaging they present communication with the distal interphalangeal joint, longer values of T2 times and lack of contrast enhancement. The angioma may strongly mimic glomus tumor as they present the same signal intensity. Nevertheless, it is more superficial and located in the papillary dermis and the epidermis.
In our case, the tumor was located in the subungual region of the right hallux. Imaging techniques demonstrated the location of the tumor and its relation with the subsequent tissues. The cytological examination revealed the nature of the tumor and its composition of vascular, myxoid and solid components.
The normal glomus body is an arteriovenous shunt that has an important role in thermoregulation and is present throughout the body in the deepest layer of the dermis, the reticular dermis. Each glomus body is an encapsulated oval organ of 300μm in length. It is located in the subungual region, digits and palms. Glomus bodies are highly concentrated in tips of the digits, particulary beneath the nails. The nail beds of fingers and toes contain 93–501 glomus bodies per square centimeter.
At clinical examination, glomus tumors are in majority non palpable lesions, frequently found in women. They usually provoke a compression to the nail matrix and thus, the principal symptom is pain at the region. A “classic triad” of clinical findings was described which include pain, point tenderness and cold sensitivity. The disappearance of the pain after application of a tourniquet proximally on the arm (Hildreth sign) is pathognominic of a glomus tumor. Eliciting pain by applying precise pressure with the tip of a pencil (Love test) helps locate the lesion.
Most glomus tumors are iso- or slightly hyperintense to the dermal layers of the nail bed on T1-weighted MR images and strongly hyperintense on T2-weighted images. The majority of them are surrounded by a capsule which has the appearance of a dark rim on T2-weighted and contrast material-enhanced imaging. The capsule is the result of a secondary reaction of the surrounding tissue and may be incomplete.
In some cases the signal intensity on T1WI and T2WI varies. It can be low or intermediate intense reflecting the variety of its histological components. The predominant cellular pattern of glomus tumors can be divided into 3 main forms: vascular , myxoid and solid. The solid or cellular type has a slightly high signal intensity on T2WI and injection of contrast medium helps its detection. The vascular type has a very strong enhancement. When the form of the tumor is myxoid the T2 times are very long. This scheme is theoretical because most tumors are composed of a mixture of the various types.
The differential diagnosis of glomus tumor includes mucoid cysts and angioma. Mucoid cysts are painless and at MRI imaging they present communication with the distal interphalangeal joint, longer values of T2 times and lack of contrast enhancement. The angioma may strongly mimic glomus tumor as they present the same signal intensity. Nevertheless, it is more superficial and located in the papillary dermis and the epidermis.
In our case, the tumor was located in the subungual region of the right hallux. Imaging techniques demonstrated the location of the tumor and its relation with the subsequent tissues. The cytological examination revealed the nature of the tumor and its composition of vascular, myxoid and solid components.
Differential Diagnosis List
Glomus tumor of the subungual region of the right hallux
Final Diagnosis
Glomus tumor of the subungual region of the right hallux
References
[1] De Schepper A (1997) Tumors of smooth muscle. In: De Schepper A: Imaging of soft tissue tumors. Berlin, Heidelberg, New York: Springer, p211-226.
[2] Drap退 JL, Idy-Peretti I, Goettmann S, Wolfram-Gabel R, Dion E, Grossin M, Benacerraf R, Gu退rin-Surville H, Bittoun J (1995) Subungual Glomus Tumors: Evaluation with MR Imaging. Radiology 195;507-515. (PMID: 7724775)
[3] Enzinger FM, Weiss SW (1995) Perivascular tumors. In: Enzinger FM, Weiss SW (eds) Soft tissue tumors, 3rd edn.Mosby, St Louis; p701-755.
[4] Blackband SJ, Chakrabarti I, Gibbs P, Buckley DL, Horsman A (1994) Fingers: three dimensional MR imaging and angiography with a local gradient coil. Radiology 190:895-899. (PMID: 8115647)
Case information
| URL: | https://www.eurorad.org/case/6606 |
| DOI: | 10.1594/EURORAD/CASE.6606 |
| ISSN: | 1563-4086 |
Figure 2
T1WI, coronal plan, after admission of contrast medium
After admission of contrast medium the tumor is strongly enhancing
Figure 3
T2 fat-suppressed weighted image, axial plan
T2 fat-suppressed weighted image demonstrating an intense high MR signal mass located in the subungual region of the right hallux
Figure 4
T2 fat-suppressed weighted image, saggital plan
High MR signal of the mass on T2 fat-suppressed weighted image
Figure 5
Histologic speciment
Neoplasmatic tissue of perivascular origin, with high cellularity, bordered by connective tissue
T1WI, coronal plan
On T1 weighted image the mass is hypointense to the muscular tissues
T1WI, coronal plan, after admission of contrast medium
After admission of contrast medium the tumor is strongly enhancing
T2 fat-suppressed weighted image, axial plan
T2 fat-suppressed weighted image demonstrating an intense high MR signal mass located in the subungual region of the right hallux
T2 fat-suppressed weighted image, saggital plan
High MR signal of the mass on T2 fat-suppressed weighted image
Histologic speciment
Neoplasmatic tissue of perivascular origin, with high cellularity, bordered by connective tissue