Three cases of subungual glomus tumors with von Recklinghausen neurofibromatosis

A case of solitary digital glomus tumor associated with neurofibromatosis type 1

An association between glomus tumor and neurofibromatosis type 1 has been reported. It is characterized by multiple tumors and young age at onset. The early diagnosis of neurofibromatosis type 1 is important because it is associated with a high rate of malignancy. A 25-year-old man presented to our hospital with left index finger pain that had persisted for 6 years. Physical and imaging findings suggested a benign soft-tissue tumor. Surgery was performed, and the tumor was pathologically diagnosed as glomus tumor. In this case, the patient with a young-onset glomus tumor was suspected of having neurofibromatosis type 1. An additional medical examination led to the diagnosis of unrecognized neurofibromatosis type 1. We experienced a case in which the onset of a glomus tumor led to the diagnosis of neurofibromatosis type 1. Comorbid neurofibromatosis type 1 should be kept in mind when glomus tumors are diagnosed.

Blue Nail Discoloration: Literature Review and Diagnostic Algorithms

Blue nail discoloration is a distinctive clinical presentation, and diagnosis is challenging given the broad differential diagnosis. A comprehensive review of the literature describing blue discoloration of one or multiple nails was performed using the PubMed, Embase, Scopus, and Web of Science databases. A total of 245 publications were included and grouped based on involvement of a single nail (monodactylic) or multiple nails (polydactylic). Monodactylic blue discoloration was associated with tumors or benign nevi, most commonly glomus tumors, followed by blue nevi and less commonly melanomas. Polydactylic blue discoloration was frequently associated with medications (such as minocycline, zidovudine, and hydroxyurea), toxic and exogenous exposures (such as silver), and other medical conditions (such as HIV/AIDS and systemic lupus erythematous). Patients presenting with blue nail discoloration warrant a thorough history, physical examination, and workup to rule out malignancy, systemic disease, or toxic exposure. We present diagnostic algorithms for monodactylic and polydactylic blue nail discoloration to guide workup and treatment plans.

Painful tumors in a patient with neurofibromatosis type 1: a case report

BACKGROUND

Herein, we report an unusual case of multifocal glomus tumors in the same hand in a patient suffering from neurofibromatosis type 1.

CASE PRESENTATION

The patient was a 37-year-old Moroccan woman, suffering from neurofibromatosis type 1, with intense pain in the fingers, successfully treated with the excision of the tumors. Histology of the lesions confirmed the diagnosis of glomus tumor.

CONCLUSION

We present this case to support the association between glomus tumors and neurofibromatosis type 1. Thus, we strongly recommend that one should suspect a glomus tumor in patients with neurofibromatosis type 1 if such patients have symptoms from finger pulp or nails.

Glomus tumor: a comprehensive review of the clinical and histopathologic features with report of two intraoral cases

BACKGROUND

Glomus tumors are benign neoplasms that most commonly present in the subungual region. Their occurrence in the oral cavity is exceedingly rare. Here, we present 2 cases from the oral cavity, detail their clinical and histopathologic features, and review the literature for solitary cases involving the oral regions.

STUDY DESIGN

The English language literature was queried for cases of benign glomus tumors in/around the oral cavity. Additional citations were cross-referenced from the identified sources.

RESULTS

Thirty-one cases of solitary glomus tumor in the oral and paraoral regions have been described, including the present cases. Patient age ranged from 10 to 85 years, with an average age of 47 years. In 12 of the 31 cases, the tumors occurred in the lips, 5 in the palate, 4 in the tongue, 4 in the buccal mucosa, 3 in the gingiva, and 1 each in the parotid, pterygoid fossa, and oropharynx. Only 18 of these cases had accompanying immunohistochemical stains, with 14 expressing positivity for muscle cell markers.

CONCLUSIONS

Although glomus tumors have distinct histopathologic features, diagnostic confusion may exist with regard to extradigital locations. Detailed documentation and discussion of the clinical and histopathologic features of rare tumors like these are vital to understanding them.

BRAF V600E Mutations Occur in a Subset of Glomus Tumors, and Are Associated With Malignant Histologic Characteristics

Glomus tumors are rare mesenchymal neoplasms with a phenotype akin to the modified smooth muscle cells of the glomus body. Most are benign, but rare examples show malignant histologic characteristics and aggressive behavior. We recently encountered a malignant glomus tumor with BRAF V600E mutation. We sought to study a large cohort for this mutation, with particular attention to associated malignant histologic characteristics. Tumors were classified based on WHO criteria as benign, uncertain malignant potential (glomus tumors of uncertain malignant potential-GT-UMP), or malignant. Tumors were screened for BRAF V600E by immunohistochemistry, and positive staining was evaluated further by Sanger sequencing. A total of 102 glomus tumors were included and classified as benign (57, 56%), GT-UMP (15, 15%) and malignant (30, 29%). Tumors occurred in patients aged 8 to 89.9 years (median: 50.2), without sex predilection (55% men). Most occurred in the superficial soft tissue (84%) and upper extremities (55%). Six of 95 tested cases had BRAF V600E mutation (6%), including 0 of 57 benign tumors, 3 of 14 GT-UMP (21%), and 3 of 24 malignant tumors (12%). Follow-up was obtained for 59 cases (median: 75.7 mo, range: 7.8 to 268.5). Three of 11 malignant tumors (27%) had progressive disease: 1 with metastasis to brain and heart, 1 with enlarging residual disease, and 1 with recurrence. Two of 4 GT-UMP (50%) had progressive disease: 1 with metastasis to lung, and 1 with local recurrence (50%). Three of 44 benign tumors (7%) had local recurrence. Two of 5 patients with BRAF V600E had progression, including 1 GT-UMP with local recurrence and 1 malignant tumor with enlarging residual disease. In summary, BRAF V600E mutation was detected in 6% of glomus tumors, all of which were malignant or GT-UMP. This mutation may be associated with a malignant phenotype, although study of additional cases is needed. In patients with progressive disease, BRAF could be a promising therapeutic target.

A Rare Case of Glomus Tumor of the Great Toe: An Analysis of Behavior at This Rare Site

Glomus tumor, originally known as an angioneuromyoma, is a benign neoplasm arising from specialized structures called glomus bodies, involved in thermoregulation. Although it has been reported at a number of sites in the body, this rare tumor is most commonly seen in the subungual areas of the digits of the hand. Only a handful of lesions have been reported in the toes. Because most foot conditions are treated by podiatrists and dermatologists, orthopaedic surgeons are generally unaccustomed to making early diagnoses. The purpose of this case report is to alert the attending surgeon regarding the possibility of glomus tumor as a cause of chronic toe pain. Also it has been observed that the behavior of this tumor varies with the site of occurrence-whether digital or extradigital. So we have extensively reviewed all similar reports in the literature to analyze the behavior of this tumor at this unusual location, apart from comparing it with the more common finger variety, to ensure it possibly is not a misclassification like the chemodectomas that were earlier thought to be glomus tumors.

LEVELS OF EVIDENCE

Therapeutic Level IV: Case Study.

Glomus tumors and neurofibromatosis: a newly recognized association

Background:

Glomus tumors are painful benign tumors arising from the neuromyoarterial elements of the glomus body, typically in a subungual location. Historically, glomus tumors have been considered isolated or sporadic, not typically associated with other disease processes. Over the last few years, however, multiple case reports, a molecular genetics study, and an epidemiologic study have confirmed an association between type I neurofibromatosis and glomus tumors. The purpose of this review is to summarize the existing information about the association between neurofibromatosis and glomus tumors and to determine whether glomus tumors that are associated with neurofibromatosis differ from isolated glomus tumors in terms of tumor number, location, and sex distribution.

Methods:

A PubMed, Ovid Medline, and Cochrane Database search was performed using the terms “glomus tumor,” “glomus tumour,” and “glomangioma” each combined with the search term “neurofibromatosis.” Fifteen English language articles were included. Information about the molecular genetics, patient sex, number of tumors per patient, and tumor location were recorded.

Results:

A total of 36 patients with glomus tumors and neurofibromatosis have been reported in the literature. Seventy-nine percent were female. Tumors were multifocal in 32% of patients, with an average of 1.4 glomus tumors per patient. Glomus tumors arose in a nonsubungual location in 38% of patients.

Conclusions:

A strong association between type I neurofibromatosis and glomus tumors has been identified. In neurofibromatosis patients with glomus tumors, the sex distribution, tumor location, and tumor burden appear similar to those in patients with isolated glomus tumors. Treating providers should be aware of this association to facilitate prompt diagnosis and treatment.

Glomus tumors in individuals with neurofibromatosis type 1

BACKGROUND

Glomus tumors have recently been reported in individuals with the neurofibromatosis type 1 (NF1) cancer disposition syndrome. We compare the clinical and molecular features of these painful hamartomas in a series of sporadic and NF1-associated cases.

OBJECTIVE

We sought to evaluate the association of NF1 with glomus tumors and to compare NF1-associated glomus tumors with sporadic glomus tumors.

METHODS

We conducted a retrospective cohort study of all individuals with a histopathologic diagnosis of glomus tumor at a large tertiary care center from January 1998 to January 2013. Charts were reviewed for a coexisting diagnosis of NF1.

RESULTS

A total of 42 glomus tumors were identified in 34 individuals. Twelve (28.6%) were found in 6 patients with NF1. In 28 individuals with 30 sporadic tumors, there was no coexisting medical condition. Although multifocal tumors (16.7%) and tumor recurrence (33.3%) were more common in association with NF1, these trends did not reach statistical significance. NF1-associated glomus tumors exhibited no neurofibromin immunoreactivity, whereas their sporadic counterparts retained neurofibromin expression.

LIMITATIONS

The retrospective design resulted in incomplete data capture.

CONCLUSIONS

Detection of glomus tumors should raise suspicion for a concurrent diagnosis of NF1.

The association between glomus tumors and neurofibromatosis

PURPOSE

To determine whether an epidemiologic association exists between glomus tumors and neurofibromatosis.

METHODS

Using a pathology database, we established a study cohort consisting of all patients who had undergone excision of a glomus tumor of the hand between 1995 and 2010. We created a control cohort by randomly selecting 200 patients who had undergone excision of a ganglion cyst over the same period. We reviewed medical records for each cohort to identify patients with a diagnosis of neurofibromatosis. We calculated the odds ratio was calculated and performed Fisher's exact test to determine the significance of the association.

RESULTS

We identified 21 patients with glomus tumors of the hand. Six of these patients carried the diagnosis of neurofibromatosis (29%). In contrast, no patients in the control group carried the diagnosis of neurofibromatosis. The odds ratio for a diagnosis of neurofibromatosis in association with a glomus tumor compared with controls was 168:1.

CONCLUSIONS

This study provides evidence of a strong epidemiologic association between glomus tumors and neurofibromatosis. Glomus tumor should be included in the differential diagnosis in neurofibromatosis patients who present with a painful lesion of the hand or finger.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Glomus tumours in the long finger and in the thumb of a young patient with neurofibromatosis-1 (Nf-1)

Glomus tumours are rare in adults, and such tumours may be associated with neurofibromatosis-1 (Nf-1). Here we describe successful treatment of two glomus tumours initially in the long finger and, one year later, in the thumb in a 17-year young girl with Nf-1.

Benign subungual tumors

A variety of benign and malignant processes may affect the subungual region; however, most are relatively rare lesions. We present a review of the current literature regarding benign tumors affecting the subungual region.

Diagnosis, management, and complications of glomus tumours of the digits in neurofibromatosis type 1

BACKGROUND

Glomus tumours are benign painful tumours of the glomus body, a thermoregulatory shunt in the digits. Glomus tumours of the fingers and toes are associated with the monogenic disorder neurofibromatosis type 1 (NF1) and are recently recognised as part of the NF1 phenotype.

METHODS AND RESULTS

A multi-institutional experience with 15 individuals with NF1 and glomus tumours of the fingers or toes is reported. The majority of individuals presented with at least two of the symptoms in the classic triad of localised tenderness, severe paroxysmal pain, and sensitivity to cold. Appearance of the nail and finger or toe is often normal. Women are affected more often than men. Multifocal tumours are common. There is often a delay in diagnosis of many years and clinical suspicion is key to diagnosis, although magnetic resonance imaging may be useful in some scenarios. Surgical extirpation can be curative; however, local tumour recurrence and metachronous tumours are common. Three of our patients developed signs and symptoms of the complex regional pain syndrome.

CONCLUSIONS

Glomus tumours in NF1 are more common than previously recognised and NF1 patients should be specifically queried about fingertip or toe pain.

A case of eccrine spiradenoma in a patient with neurofibromatosis

Neurofibromatosis is a systemic hereditary disorder with varied manifestations in bone, soft tissue, the nervous system and skin. Cutaneous manifestations of neurofibromatosis are characterized by café-au-lait macules, multiple neurofibromas, Lisch nodules and intertriginous freckling. Some benign or malignant tumors such as juvenile xanthogranuloma, pheochromocytoma, and malignant melanoma can accompany neurofibromatosis. But, in the English literature, no case of eccrine spiradenoma associated with neurofibromatosis has been reported. Eccrine spiradenoma is a benign uncommon neoplasm of skin adnexa. It presents as a painful, slow-growing and solitary nodule on the head or upper trunk. Here, we report a rare case of eccrine spiradenoma in a patient with neurofibromatosis.

Neurofibromatosis type 1

Neurofibromatosis type 1 (NF1) is an autosomal dominant, multisystem disorder affecting approximately 1 in 3500 people. Significant advances in the understanding of the pathophysiology of NF1 have been made in the last decade. While no medical therapies for NF1 are currently available, trials are ongoing to discover and test medical treatments for the various manifestations of NF1, primarily plexiform neurofibromas, learning disabilities, and optic pathway gliomas. In addition, mutational analysis has become available on a clinical basis and is useful for diagnostic confirmation in individuals who do not fulfill diagnostic criteria or when a prenatal diagnosis is desired. There are several disorders that may share overlapping features with NF1; in 2007, a disorder with cutaneous findings similar to NF1 was described. This paper addresses the dermatologist's role in diagnosis and management of NF1 and describes the variety of cutaneous and extracutaneous findings in NF1 to which the dermatologist may be exposed.

LEARNING OBJECTIVES

After completing this learning activity, participants should be able to discuss the indications and limitations of genetic testing in neurofibromatosis type 1, distinguish common and uncommon cutaneous findings, and recognize the dermatologist's role in diagnosis and management.

Glomus tumors in neurofibromatosis type 1: genetic, functional, and clinical evidence of a novel association

Neurofibromatosis type 1 (NF1) is a common disorder that arises secondary to mutations in the tumor suppressor gene NF1. Glomus tumors are small, benign but painful tumors that originate from the glomus body, a thermoregulatory shunt concentrated in the fingers and toes. We report 11 individuals with NF1 who harbored 20 glomus tumors of the fingers and 1 in the toe; 5 individuals had multiple glomus tumors. We hypothesized that biallelic inactivation of NF1 underlies the pathogenesis of these tumors. In 12 NF1-associated glomus tumors, we used cell culture and laser capture microdissection to isolate DNA. We also analyzed two sporadic (not NF1-associated) glomus tumors. Genetic analysis showed germ line and somatic NF1 mutations in seven tumors. RAS mitogen-activated protein kinase hyperactivation was observed in cultured NF1(-/-) glomus cells, reflecting a lack of inhibition of the pathway by functional neurofibromin, the protein product of NF1. No abnormalities in NF1 or RAS mitogen-activated protein kinase activation were found in sporadic glomus tumors. By comparative genomic hybridization, we observed amplification of the 3'-end of CRTAC1 and a deletion of the 5'-end of WASF1 in two NF1-associated glomus tumors. For the first time, we show that loss of neurofibromin function is crucial in the pathogenesis of glomus tumors in NF1. Glomus tumors of the fingers or toes should be considered as part of the tumor spectrum of NF1.

Common nail tumors

Nail abnormalities are varied and numerous. They include warts, keratoacanthomas, onychomatricomas, fibrokeratomas, osteochondromas, tumors (ie, glomus, giant cell, Koenen's, and others), and Bowen's disease. Although the gravity of these conditions may vary, prompt diagnosis and treatment is of the utmost importance. This article discusses the most common defects associated with the nail unit and its surrounding tissue, as well as the differential diagnosis and treatment of these conditions.